Psychologist Template

Initial Clinical Interview

About this template

This Initial Clinical Interview template is designed for psychologists and counsellors conducting first appointments with clients. It covers a comprehensive range of topics including presenting problems, current functioning, psychiatric and medical history, developmental and social history, substance use, risk assessment, and mental state examination. This template ensures that all relevant details are captured to provide a thorough understanding of the client's mental health. Ideal for clinical psychologists, this template helps streamline the documentation process, ensuring no critical information is missed during the initial assessment.

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CLINICAL INTERVIEW: PRESENTING PROBLEM(s) - Client reports experiencing severe anxiety and panic attacks. - Client mentions difficulty concentrating at work due to anxiety. HISTORY OF PRESENTING PROBLEM(S) - History of Presenting Problem(s): Client's anxiety began approximately six months ago, with symptoms gradually worsening over time. Panic attacks occur 2-3 times per week, with each episode lasting about 20-30 minutes. CURRENT FUNCTIONING - Sleep: Client reports difficulty falling asleep and frequent awakenings during the night, averaging 4-5 hours of sleep per night. - Employment/Education: Client is currently employed as a software engineer but finds it challenging to focus on tasks due to anxiety. - Family: Client lives with their spouse and two children. The anxiety has caused strain in the relationship with their spouse. - Social: Client has a few close friends but has been avoiding social gatherings due to anxiety. - Exercise/Physical Activity: Client used to jog regularly but has stopped due to lack of motivation and energy. - Eating Regime/Appetite: Client reports a decreased appetite and irregular eating patterns. - Energy Levels: Client feels fatigued throughout the day, with energy levels peaking in the late afternoon. - Recreational/Interests: Client used to enjoy reading and painting but has lost interest in these activities. CURRENT MEDICATIONS - Current Medications: Client is currently taking 10mg of Lexapro daily for anxiety. PSYCHIATRIC HISTORY - Psychiatric History: Client has no prior psychiatric hospitalisations but has attended counselling sessions intermittently over the past few years. MEDICAL HISTORY - Personal and Family Medical History: Client has a history of hypertension. Family history includes a mother with depression. DEVELOPMENTAL, SOCIAL AND FAMILY HISTORY Family: - Family of Origin: Client was raised by both parents, who are now divorced. Client has one younger sibling. Educational History - Educational History: Client completed a bachelor's degree in computer science. No significant academic issues reported. Employment History - Employment History: Client has been employed in the tech industry for the past 10 years. No major employment issues reported. Relationship History - Relationship History: Client has been married for 8 years. Reports occasional conflicts with spouse, primarily related to anxiety. SUBSTANCE USE - Substance Use: Client occasionally consumes alcohol, approximately 1-2 drinks per week. No history of drug use. RELEVANT CULTURAL/RELIGIOUS/SPIRITUAL ISSUES - Relevant Cultural/Religious/Spiritual Issues: Client identifies as Christian and finds comfort in prayer during times of stress. RISK ASSESSMENT Risk Assessment: - Suicidal Ideation: Client denies any history of suicidal ideation or attempts. - Homicidal Ideation: Client denies any homicidal ideation. - Self-harm: Client denies any history of self-harm. - Violence & Aggression: Client denies any incidents of violence or aggression. - Risk-taking/Impulsivity: Client denies any risk-taking behaviours or impulsivity. MENTAL STATE EXAM: - Appearance: Client appears well-groomed and appropriately dressed. - Behaviour: Client is cooperative and maintains good eye contact. - Speech: Speech is clear and coherent. - Mood: Client reports feeling anxious and overwhelmed. - Affect: Affect is congruent with mood, showing signs of anxiety. - Perception: No hallucinations or dissociations reported. - Thought Process: Thought process is logical and goal-directed. - Thought Form: No disorderly thoughts observed. - Orientation: Client is oriented to time and place. - Memory: Memory function appears intact. - Concentration: Client reports difficulty concentrating at work. - Attention: Attention span is adequate during the interview. - Judgement: Judgement appears sound. - Insight: Client has good insight into their condition and is motivated to seek help. TEST RESULTS Summary of Findings: No formal psychometric assessments or self-report measures were conducted during this session. DIAGNOSIS: - Diagnosis: Generalised Anxiety Disorder (GAD) CLINICAL FORMULATION: - Presenting Problem: Client reports severe anxiety and panic attacks, affecting daily functioning and relationships. - Predisposing Factors: Family history of depression, high-stress job. - Precipitating Factors: Increased workload and job-related stress. - Perpetuating Factors: Avoidance of social situations, lack of physical activity. - Protecting Factors: Supportive spouse, motivation to seek help. Case formulation: Client presents with severe anxiety and panic attacks, which appear to be precipitated by increased workload and job-related stress. Factors that seem to have predisposed the client to the anxiety include a family history of depression and a high-stress job. The current problem is maintained by avoidance of social situations and lack of physical activity. However, the protective and positive factors include a supportive spouse and motivation to seek help.

(The template or structure below is intended to be used for a first appoinments with clinical psychologists, It is important that you note that the details of the topics discussed in the transcript may vary greatly between patients, as a large proportion of the information intended for placeholders in square brackets in the template or structure below may already be known. If there is no specific mention in the transcript or contextual notes of the relevant information for a placeholder below, you should not include the placeholder in the clinical note or document that you output - instead you should leave it blank. Do not hallucinate or make up any information for a placeholder in the template or structure below if it is not mentioned or present in the transcript. The topics discussed in the transcript by clinical psychologists are sometimes not well-defined clinical disease states or symptoms and are often just aspects of the patient's life that are important to them and they wish to discuss with their clinician. Therefore it is vital that the entire transcript is used and included in the clinical note or document that you output, as even brief topic discussions may be an important part of the patient's mental health care. The placeholders below should therefore be used as a rough guide to how the information in the transcript should be captured in the clinical note or document, but you should interpret the topics discussed and then use your judgement to either: exclude sections from the template or structure below because it is not relevant to the clinical note or document based on the details of the topics discussed in the transcript, or include new sections that are not currently present in the template or structure, in order to accurately capture the details of the topics discussed in the transcript. Remember to use as many bullet points as you need to capture the relevant details from the transcript for each section. Do not respond to these guidelines in your output, you must only output the clinical note or document as instructed.) CLINICAL INTERVIEW: "PRESENTING PROBLEM(s)" - [Detail presenting problems.] (use as many bullet points as needed to capture the reason for the visit and any associated stressors in detail) (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank) HISTORY OF PRESENTING PROBLEM(S) - History of Presenting Problem(s): [Detail the history of the presenting Problem(s) and include onset, duration, course, and severity of the symptoms or problems.] (use as many bullet points as needed to capture when the symptoms or problem started, the development and course of symptoms) (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank) CURRENT FUNCTIONING - Sleep: [Detail sleep patterns.] (use as many bullet points as needed to capture the sleep pattern and how the problem has affected sleep patterns) (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank). - Employment/Education: [Detail current employment or educational status.] (use as many bullet points as needed to capture current employment or educational status and how the symptoms or problem has affected current employment or education) (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank). - Family: [Detail family dynamics and relationships.] (use as many bullet points as needed to capture names, ages of family members and the relationships with each other and the effect of symptoms on the family dynamics and relationships) (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank). - Social: [Describe social interactions and the patient’s support network.] (use as many bullet points as needed to capture the social interactions of the patient and the patient’s support network) (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank). - Exercise/Physical Activity: [Detail exercise routines or physical activities] (use as many bullet points as needed to capture all exercise and physical activity and the effect the symptoms have had on the patient’s exercise and physical activity) (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - Eating Regime/Appetite: [Detail the eating habits and appetite] (use as many bullet points as needed to capture all eating habits and appetite and the effect the symptoms have had on the patient’s eating habits and appetite) (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank). - Energy Levels: [Detail energy levels throughout the day and the effect the symptoms have had on energy levels] (use as many bullet points as needed to capture the patient’s energy levels and the effect the symptoms or problems have had on the patient’s energy levels) (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank) - Recreational/Interests: [Mention hobbies or interests and the effect the patient’s symptoms have had on their hobbies and interests] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank) CURRENT MEDICATIONS - Current Medications: [List type, frequency, and daily dose in detail] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank) PSYCHIATRIC HISTORY - Psychiatric History: [Detail any psychiatric history including hospitalisations, treatment from psychiatrists, psychological treatment, counselling, and past medications – type, frequency and dose] (use as many bullet points as needed to capture the patient’s psychiatric history) (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank) - Other interventions: [Detail any other interventions not mentioned in Psychiatric History] (Use as many bullet points as needed to capture all interventions) (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank) MEDICAL HISTORY - Personal and Family Medical History: [Detail personal and family medical history] (Use as many bullet points as needed to capture the patient’s medical history and the patient’s family medical history) (only include if explicitly mentioned in the contextual notes or clinical note, otherwise leave blank) DEVELOPMENTAL, SOCIAL AND FAMILY HISTORY Family: - Family of Origin [Detail the family of origin] (use as many bullet points as needed to capture the patient’s family at birth, including parent’s names, their occupations, the parent's relationship with each other, and other siblings) (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank) Developmental History: - Developmental History [Detail developmental milestones and any issues] (use as many bullet points as needed to capture developmental history) (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank) Educational History - Educational History: [Detail educational history, including academic achievement, relationship with peers, and any issues] (use as many bullet points as needed to capture educational history) (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank) Employment History - Employment History: [Detail employment history and any issues] (use as many bullet points as needed to capture employment history) (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank) Relationship History - Relationship History: [Detail relationship history and any issues] (use as many bullet points as needed to capture the relationship history) (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank) Forensic/Legal History - Forensic and Legal History: [Detail any forensic or legal history] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank) SUBSTANCE USE - Substance Use: [Detail any current and past substance use] (use as many bullet points as needed to capture current and past substance use including type and frequency) (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank) RELEVANT CULTURAL/RELIGIOUS/SPIRITUAL ISSUES - Relevant Cultural/Religious/Spiritual Issues: [Detail any cultural, religious, or spiritual factors that are relevant] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank) RISK ASSESSMENT Risk Assessment: - Suicidal Ideation: [History, attempts, plans] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank) - Homicidal Ideation: [Describe any homicidal ideation] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank) - Self-harm: [Detail any history of self-harm] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank) - Violence & Aggression: [Describe any incidents of violence or aggression] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank) - Risk-taking/Impulsivity: [Describe any risk-taking behaviors or impulsivity] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank) MENTAL STATE EXAM: - Appearance: [Describe the patient's appearance] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank) - Behaviour: [Describe the patient's behaviour] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank) - Speech: [Detail speech patterns] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank) - Mood: [Describe the patient's mood] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank) - Affect: [Describe the patient's affect] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank) - Perception: [Detail any hallucinations or dissociations] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank) - Thought Process: [Describe the patient's thought process] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank) - Thought Form: [Detail the form of thoughts, including any disorderly thoughts] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank) - Orientation: [Detail orientation to time and place] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank) - Memory: [Describe memory function] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank) - Concentration: [Detail concentration levels] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank) - Attention: [Describe attention span] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank) - Judgement: [Detail judgement capabilities] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank) - Insight: [Describe the patient's insight into their condition] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank) TEST RESULTS Summary of Findings: [Summarize the findings from any formal psychometric assessments or self-report measures] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank) DIAGNOSIS: - Diagnosis: [List any DSM-5-TR diagnosis and any comorbid conditions] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank) CLINICAL FORMULATION: - Presenting Problem: [Summarise the presenting problem] (Use as many bullet points as needed to capture the presenting problem) (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank) - Predisposing Factors: [List predisposing factors to the patient's condition] (Use as many bullet points as needed to capture the predisposing factors) (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank) - Precipitating Factors: [List precipitating factors that may have triggered the condition] (Use as many bullet points as needed to capture the precipitating factors) (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank) - Perpetuating Factors: [List factors that are perpetuating the condition] (Use as many bullet points as needed to capture the perpetuating factors) (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank) - Protecting Factors: [List factors that protect the patient from worsening of the condition] (Use as many bullet points as needed to capture the protective factors) (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank) Case formulation: [Detail a case formulation as a paragraph] [Client presents with (problem), which appears to be precipitated by (precipitating factors). Factors that seem to have predisposed the client to the (problem) include (predisposing factors). The current problem is maintained by (perpetuating factors). However, the protective and positive factors include (Protective factors)]. (Ensure all information discussed in the transcript is included under the relevant heading or sub-heading above, otherwise include it as a bullet-pointed additional note at the end of the note.) (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 include 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 section blank.) (Always use the word "Client" instead of the word "patient" or their name.) (Ensure all information is super detailed and do not use quotes.)

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Specialty

Psychologist

Used

2626 times

Type

Note

Last edited

6/25/2025

Created by

Olga Lavalle

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