Psychology Intake Assessment Note 2.0

Behavioural Observations & Mental Status Examination: [Provide a detailed description of client's appearance and grooming, observations of the client's engagement and cooperation during the assessment, a description of client's speech characteristics, a description of the client's reported mood and observed affect, observation of client's thought process and content, assessment of client's alertness, orientation, and cognitive functioning, a description of the client's insight into current stressors and need for support, an assessment of the client's judgment, an assessment of the client's suicidal ideation, intent, or plan] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Relevant History: [Provide a detailed summary of all of the information the client related to discussed demographic information, including age, gender, occupation, and place of birth, childhood history, a summary of the client's childhood experiences, including frequent moves and family dynamics, a detailed summary of the client's relationships with family members, including parents and siblings, a detailed summary of the client's educational background and any information related to learning difficulties and learning styles, a detailed summary of the client's occupational history, current occupational responsibilities and duties, and current work-related stressors, a detailed summary of client's current living situation and family composition, a detailed summary of the client's relationship history and interpersonal functioning, a detailed summary of the clients past psychological and medical functioning including any diagnoses and symptoms, a description of client's current marital relationship, including satisfaction, communication, and sexual issues, a summary of the client's substance use history and any current concerns] (include all of the information provided in the transcript and context) (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Family History: [Provide a summary of the client's family medical and mental health history] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Presenting Complaints: [Provide a detailed summary of all of the client's reported current symptoms and complaints, and include all of the provided examples] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Medical & Mental Health History: [List all of the client's past and present medical diagnoses and a summary of the client's previous mental health diagnoses and treatment and outcomes] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Psychological Measures: [Provide a detailed summary of all of the standardized psychological assessments administered and the interpretation] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Diagnosis/Conceptualization: [Provide a summary of the diagnostic impressions based on client's presentation and assessment results, and brief conceptualization of client's symptoms and contributing factors] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Proposed Treatment Plan: [Provide a summary of recommended therapeutic approaches, outline of specific treatment goals and interventions, plan for addressing client's anxiety, depression, sleep difficulties, social anxiety, and work-related stressors, description of skills and techniques to be taught, plan for monitoring progress and adjusting treatment as needed, frequency of sessions and client's agreement to the proposed schedule] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) [Scheduling of client's next session, including date and time] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) (For each section, only include if explicitly mentioned in transcript or context, else omit section entirely. Never come up with your own patient details, assessment, plan, interventions, evaluation, or next steps—use only the transcript, contextual notes, or clinical note as reference for all information. If any information related to a placeholder has not been explicitly mentioned, do not state that in the output; simply leave the relevant placeholder or section out entirely. Use as many lines, paragraphs, or bullet points as needed to capture all relevant information from the transcript.)