Therapist Template

Intake Report for Psychotherapy

A professional Therapist template for healthcare professionals.

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Specialty

Therapist

Used

45 times

Type

Note

Last edited

6/16/2025

Created by

Jane Smith

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About this template

The Intake Report for Psychotherapy template is an essential tool for therapists conducting initial assessments of new clients. This comprehensive template helps document referral reasons, family makeup, background information, psychosocial history, and life history. It also includes sections for setting treatment expectations and goals, as well as conducting a mental status examination. This template is ideal for therapists seeking to create detailed and structured intake reports, ensuring all relevant client information is captured for effective treatment planning. Use this template with Heidi to streamline your documentation process and enhance client care.

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Intake Report for Psychotherapy: Referral Reason: - The client, a 32-year-old female, has been experiencing increased anxiety and difficulty sleeping due to work-related stress and recent family conflicts. Family makeup: - The client is married with two children, ages 5 and 8. Her husband is supportive, but they have been experiencing communication issues. The client works as a marketing manager, and her children attend primary school. - Family history includes a maternal history of anxiety disorders. Background Information - The client reports a history of anxiety since her teenage years, with occasional panic attacks. She has not undergone any surgeries. - Currently taking sertraline 50mg daily for anxiety. No herbal supplements. - No known allergies. Psychosocial History: - The client has a strong social network but has been withdrawing from friends due to stress. - She holds a bachelor's degree in marketing and has been in her current job for 5 years. - The client has been married for 10 years, with a generally stable relationship, though recent stress has caused some tension. Life history/family history: The client grew up in a supportive family environment, with both parents working in education. She has one sibling, a younger brother, who is also experiencing anxiety issues. Financially stable, with no significant hospitalizations in the family. Expectations/goals for treatment: - The client aims to reduce anxiety levels, improve sleep quality, and enhance communication with her husband. Impressions: The client presents as motivated and articulate, with moderate stress levels. She is committed to therapy and shows no unusual behavior. Mental Status Examination: - Appearance: Neatly dressed, well-groomed. - Behavior: Cooperative and engaged. - Mood: Anxious but hopeful. - Affect: Congruent with mood. - Thought Process: Logical and coherent. - Thought Content: Focused on stressors and family dynamics. - Cognition: Intact, oriented to time, place, and person. - Insight: Good understanding of her condition. - Judgment: Sound decision-making skills. Assessment: - Generalized Anxiety Disorder with situational stressors. Plan: - Begin cognitive-behavioral therapy (CBT) to address anxiety and improve coping strategies. Schedule weekly sessions for the next 8 weeks.