Couple Intake and Formulation

Presenting problem: [describe the primary reasons for the couple seeking therapy, including the core issues they identify, the duration of these problems, and how they impact the relationship] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) History of problem: [detail the chronological development of the presenting problems, including precipitating events, previous attempts to resolve issues, and any patterns of escalation or de-escalation] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) Process notes: [document observations about the couple's interaction during the session, including communication patterns, emotional expressions, non-verbal cues, and dynamic between partners and with the therapist] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) Hopes and fears for therapy: [describe the individual and shared expectations and concerns regarding the therapeutic process and potential outcomes, including desired changes and anxieties about addressing difficult topics] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) Presence of depression/other mental illness in one or both partners: [identify any history or current presentation of depression or other mental health conditions in either partner, including diagnoses, symptoms, and impact on the individual and the relationship] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) General medical conditions: [document any relevant current or past general medical conditions for either partner, including chronic illnesses, significant health events, and their potential influence on well-being or relationship dynamics] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) Medication: [list any current medications being taken by either partner, including prescriptions, over-the-counter drugs, and supplements, noting dosages and reasons for use] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) Previous therapy/counseling: [detail any prior individual or couples therapy experiences for either partner, including the type of therapy, duration, perceived effectiveness, and reasons for termination] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) Couple: [describe the couple's overall dynamic, including their strengths, challenges, current stage of relationship, and any significant events or transitions they have experienced together] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) Partner 1: [provide relevant individual information for Partner 1, including demographic details, relevant personal history, and individual perspectives on the relationship and presenting problems] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) Partner 2: [provide relevant individual information for Partner 2, including demographic details, relevant personal history, and individual perspectives on the relationship and presenting problems] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) Family (current): [describe the current family structure and relationships for each partner, including interactions with children, extended family, and the influence of these relationships on the couple] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) Family (history): Partner 1: Relationship with mother: [detail Partner 1's historical relationship with their mother, including the nature of attachment, significant events, and perceived impact on current relational patterns] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) Relationship with father: [detail Partner 1's historical relationship with their father, including the nature of attachment, significant events, and perceived impact on current relational patterns] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) Parents relationship with each other: [describe Partner 1's perception and experience of their parents' relationship, including observed dynamics, conflict resolution, and overall stability] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) Sibling relationships: [describe Partner 1's historical and current relationships with siblings, including birth order, significant dynamics, and perceived influence on their personality or relational style] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) Partner 2: Relationship with mother: [detail Partner 2's historical relationship with their mother, including the nature of attachment, significant events, and perceived impact on current relational patterns] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) Relationship with father: [detail Partner 2's historical relationship with their father, including the nature of attachment, significant events, and perceived impact on current relational patterns] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) Parents relationship with each other: [describe Partner 2's perception and experience of their parents' relationship, including observed dynamics, conflict resolution, and overall stability] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) Sibling relationships: [describe Partner 2's historical and current relationships with siblings, including birth order, significant dynamics, and perceived influence on their personality or relational style] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) Love maps and rituals of connection: [describe the couple's knowledge of each other's inner worlds (love maps) and their established routines for emotional connection, affection, and shared meaning (rituals of connection)] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) Friendships/support network: [document the extent and quality of each partner's and the couple's social support networks, including friendships, community involvement, and other sources of external support] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) Education: [detail the educational background of each partner, including highest level of education achieved and any significant academic experiences] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) Employment history: [summarize the employment history of each partner, including current occupation, career stability, job satisfaction, and any work-related stressors] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) Substance use: [document any current or historical substance use by either partner, including alcohol, illicit drugs, or misuse of prescription medications, noting frequency, quantity, and impact] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) Conflict style: [describe the couple's typical patterns and strategies for managing disagreements and conflict, including communication styles, escalation, de-escalation, and resolution attempts] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) Domestic violence: [identify any history or current presence of domestic violence, including physical, emotional, sexual, or financial abuse, noting the nature and frequency of incidents and impact on safety] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) Affairs: [document any history of infidelity or extramarital affairs, including details of the affair(s), their impact on the relationship, and how the couple has addressed or is addressing the aftermath] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) Other: [include any other relevant information not covered in previous sections that is pertinent to the couple's dynamics, individual well-being, or therapeutic process] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) 1. Shared fantasy and shared fears and anxieties: [describe the collective hopes, ideals, and unconscious expectations the couple holds for their relationship, as well as their mutual anxieties, worries, or underlying insecurities that impact their dynamic] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) 2. Internalised image of a couple: [describe the unconscious template or model of a relationship that each partner carries, often derived from their family of origin or past experiences, and how these internalised images interact within the couple's dynamic] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) 3. What is/are the unconscious fit and unconscious beliefs and unconscious contract: [describe the unstated, often unspoken agreements or understandings between partners that shape their interaction, including how their individual unconscious needs, beliefs, and patterns align or clash] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) 4. Is the relationship largely developmental or defensive?: [assess whether the primary function of the relationship is to foster growth and maturity (developmental) or to protect against anxiety, past traumas, or perceived threats (defensive), noting the predominant mode] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) 5. Defences: Shared defences;Primitive defences / more mature: [identify the psychological defence mechanisms employed by the couple, both individually and collectively, categorising them as primitive (e.g., denial, splitting) or more mature (e.g., humour, sublimation) and noting their impact on problem-solving] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) 6. Dominant developmental stage of the relationship: Paranoid schizoid / Depressive position: [determine the predominant psychological position or stage of development the couple is operating from, based on Melanie Klein's theories, noting whether they are primarily in a state of splitting and fear (paranoid-schizoid) or integration and concern (depressive position)] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) 7. Is this a more neurotic / more narcissistic / more borderline couple?: [characterise the couple's dynamic based on dominant personality organisation patterns, noting whether their conflicts and interactions primarily stem from neurotic (internal conflict, anxiety), narcissistic (self-centredness, grandiosity), or borderline (instability, intense emotions) traits] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) 8. Projective Identification: What is projected, by whom? Is the function of projection defensive / communicative?: [describe instances where one partner unconsciously attributes their own unacceptable feelings or parts of self onto the other, detailing what is projected, who is projecting and receiving, and whether the purpose is primarily to defend against internal distress or to communicate something difficult] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) 9. Repetition Compulsion: What is each repeating?: [identify patterns of behaviour, interaction, or relational outcomes that the couple or individual partners repeatedly reenact, often unconsciously, from past experiences or unresolved conflicts] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) 10. Attachment: Secure / Insecure – Dismissive / dismissive; Preoccupied / preoccupied; Dismissive / preoccupied: [assess the primary attachment styles of each partner and their combination within the couple's dynamic, categorising them as secure, or insecure (dismissing-avoidant, preoccupied-anxious), and noting how these styles influence their relational patterns] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) 11. Life Events /changes affecting unconscious contract: [document significant life transitions or events (e.g., job loss, birth of child, illness, bereavement) that have impacted the couple's unspoken agreements, expectations, or underlying dynamics] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) 12. Can the couple be creative and curious?: [assess the couple's capacity for flexibility, openness to new experiences, willingness to explore their own and each other's internal worlds, and their ability to generate new solutions or perspectives] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) 13. Transference – onto each other; onto therapist: [describe instances of transference, where partners unconsciously project past relationship patterns or feelings onto each other or onto the therapist, noting the content and origin of these projections] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) 14. Countertransference and possibility of couple state of mind: [document the therapist's emotional and psychological reactions to the couple, identifying any countertransference responses, and noting the overall emotional or psychological atmosphere created by the couple's dynamic (couple state of mind)] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) 15. Task of therapy: [summarize the core therapeutic goals and the primary focus for intervention with the couple, outlining the work to be undertaken to address their presenting problems and facilitate growth] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) Context summary brief summary to copy Into Heidi context for tracking key issues, dynamics, treatment goals in the psychotherapy process as it unfolds (Never come up with your own patient details, assessment, plan, interventions, evaluation, and plan for continuing care - use only the transcript, contextual notes or clinical note as a reference for the information included in your note. If any information related to a placeholder has not been explicitly mentioned in the transcript, contextual notes or clinical note, you must not state the information has not been explicitly mentioned in your output, just leave the relevant placeholder or omit the placeholder completely.) (Use as many lines, paragraphs or bullet points, depending on the format, as needed to capture all the relevant information from the transcript.)