Child Therapy Intake Note

Client Information: - Client Name: [Insert client name here] (only include if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise leave blank.) - Provider Name: [Insert provider name here] (only include if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise leave blank.) - Date of Service: [Insert date of service here] - Session Duration: [Insert session duration here] Brief Summary of Session: [Provide a concise summary of the session, including purpose, major topics discussed, client engagement, and key outcomes.] Consent: - Informed Consent: [Detail the informed consent process, including confidentiality limits and client rights and responsibilities. Note if the client and/or guardian signed the consent form.] - Quote (Consent): [Insert client or guardian quote about understanding consent, if available.] Presenting Problem: - Chief Complaint: [Describe the main issues that brought the client to therapy, including any relevant referral information.] - Quote (Chief Complaint): [Insert quote from client or guardian regarding the chief complaint.] - Impairments and Challenges: [Detail how the presenting problem is affecting the client’s functioning in different areas of life.] - Quote (Impairments and Challenges): [Insert client or guardian quote about the impact of the problem.] Psychological Factors: - Family Mental Health History: [Detail relevant family history of mental health issues.] - Previous Mental Health Treatments: [Note any prior therapy or psychiatric treatment.] - Symptom Description: [Describe specific symptoms, including onset, frequency, duration, and intensity.] - Quotes (Symptoms): [Include any quotes from the client or guardian regarding symptoms.] Biological Factors: - Medications: [List current medications, if any.] - Allergies: [Detail known allergies.] - Medical Conditions: [List any reported medical conditions.] - Sleep: [Describe sleep patterns and issues.] - Nutrition: [Detail eating habits and any concerns.] - Physical Activity: [Summarize current activity levels and any limitations.] Social Factors: - School: [Describe academic performance, attendance, and challenges.] - Relationships: [Summarize family dynamics, peer interactions, and social support.] - Recreation: [Note hobbies, interests, and changes in activity level.] - Recent Changes or Stressors: [Detail recent life changes or stressors impacting the client.] - Traumatic Experiences: [List any reported or suspected traumas.] Clinical Assessment: - Clinical Conceptualization: [Summarize the therapist’s understanding of the problem based on biological, psychological, and social factors.] - Diagnosis: [Provide DSM-5 and/or ICD-10 diagnosis, if applicable.] - Reasoning: [Explain how the diagnosis aligns with presenting symptoms.] - Assessment Tool: [List any assessment tools used and their results.] - Status: [Note the status of the intake process and any planned follow-up assessments.] Mental Status Exam: - Mood and Affect: [Describe the client’s emotional state and expression.] - Speech and Language: [Note any abnormalities in speech or communication.] - Thought Process and Content: [Summarize the client’s thought patterns.] - Orientation: [Document orientation to person, place, and time.] - Cognition: [Assess attention, memory, and problem-solving abilities.] - Insight: [Comment on the client’s understanding of their condition.] Risk Assessment: - Safety Concerns: [Document any concerns related to self-harm, harm to others, or other risks.] - Quotes (Risk): [Include client or guardian statements regarding risks or safety.] - Safety Plan: [Note any immediate interventions or monitoring plans.] Strengths and Resources: - Internal Strengths: [Highlight the client’s strengths, skills, and resilience.] - External Resources: [Document supportive relationships and other resources.] - Quote (Resources): [Include quotes that reflect optimism or strengths.] Interventions: - Therapeutic Approach: [Detail the therapeutic approach or modality used.] - Specific Interventions: [Describe interventions introduced during the session.] - Rationale: [Explain why these interventions are appropriate for the presenting problem.] Progress and Response: - Client Engagement: [Comment on the client’s participation and receptivity.] - Specific Examples: [Provide examples of progress or challenges observed.] - Quote (Progress): [Include client or guardian statements about progress or goals.] - Challenges: [Note any barriers to progress.] Goals: 1. Goal: - Description: [Detail the goal.] - Metrics: [Describe how progress will be measured.] - Timeframe: [Specify the expected timeline for achieving the goal.] - Quote (Goal): [Include a relevant quote about the goal.] 2. Goal: - Description: [Detail the goal.] - Metrics: [Describe how progress will be measured.] - Timeframe: [Specify the expected timeline for achieving the goal.] - Quote (Goal): [Include a relevant quote about the goal.] [Add additional goals as needed.] Follow-Up Plan: - Homework: [Outline any tasks or practices assigned to the client.] - Next Session Plan: [Describe the focus or activities planned for the next session.] - Coordination of Care: [Note any collaboration with other providers or stakeholders.] - Long-Term Plan: [Summarize the treatment trajectory, including frequency of sessions.]