Initial Assessment Template (Therapy)

Identifying Information:

Client is a 35-year-old cisgender female (she/her pronouns) who identifies as Asian American. She works as a software engineer and lives with her partner of 5 years. Client was referred by her primary care physician after reporting symptoms of depression and requesting mental health services. This is her first time seeking therapy.

Presenting Problem:

Client reports experiencing persistent feelings of sadness and emptiness for the past six months, which she describes as "feeling like I'm just going through the motions." Symptoms include difficulty concentrating at work, loss of interest in previously enjoyed activities such as painting and hiking, and social withdrawal. She reports crying episodes 3-4 times per week, typically in the evenings, and states she feels "exhausted all the time" despite sleeping 9-10 hours per night. Client denies specific triggering event but notes the symptoms began gradually after her company underwent restructuring. Impact on functioning includes decreased work productivity, strained relationship with partner due to emotional unavailability, and cessation of creative hobbies.

Relevant History:

Client reports one previous episode of depression in college (age 20) following a breakup, which resolved without treatment after approximately 3 months. No prior psychiatric hospitalizations or suicide attempts. Mother has history of depression and anxiety, currently managed with medication. Father has history of alcohol use disorder, now in recovery for 10 years. No significant medical conditions. Client had wisdom teeth extraction at age 18 with no complications. Denies history of trauma or abuse. Reports moderate alcohol use (2-3 drinks on weekends), denies drug use. Describes childhood as "relatively stable" with some family conflict related to father's drinking. Graduated with honors from university, maintained strong friendships through college.

Mental Status Examination:

Appearance: Casually dressed, appropriate for season. Good hygiene and grooming. Behavior: Cooperative and engaged, though appeared somewhat withdrawn. Maintained intermittent eye contact. Speech: Normal rate and volume, occasionally hesitant when discussing emotional topics. Mood: "Sad and tired." Affect: Constricted and congruent with stated mood, brightened briefly when discussing partner's support. Thought process: Linear and goal-directed. Thought content: Preoccupied with work performance concerns and feelings of inadequacy. Denies current suicidal or homicidal ideation. No delusions, hallucinations, or obsessions reported. Cognition: Alert and oriented to person, place, time, and situation. Memory and concentration appeared intact though client reports subjective difficulties. Insight: Good - recognizes symptoms as problematic and seeks help. Judgment: Intact - making appropriate life decisions and safety planning.

Risk Assessment:

Client denies current suicidal ideation, intent, or plan. Reports passive thoughts of "not wanting to be here" occasionally but states these are fleeting and not acted upon. No history of self-harm or suicide attempts. Protective factors include supportive partner, stable employment, no access to lethal means, and motivation for treatment. Client denies homicidal ideation or intent to harm others. Given low acute risk, safety planning focused on identifying warning signs and coping strategies. Client agreed to contact crisis line or go to emergency room if thoughts of self-harm intensify.

Strengths and Resources:

Client demonstrates several significant strengths including good insight into her symptoms, strong motivation for treatment, and history of resilience (recovered from previous depressive episode, successfully navigated career challenges). She has a supportive partner who is aware of her struggles and encouraging of therapy. Client has stable employment and adequate financial resources for treatment. She has previously enjoyed creative outlets and exercise, indicating potential coping mechanisms to reactivate. Client is articulate and able to reflect on her experiences, which will facilitate therapeutic work.

Clinical Impressions:

Provisional diagnosis: Major Depressive Disorder, moderate severity (F33.1). Client presents with at least five symptoms meeting DSM-5 criteria for major depressive episode including depressed mood, anhedonia, fatigue, sleep disturbance, and difficulty concentrating, persisting for six months. Symptoms cause significant impairment in occupational and social functioning. Rule out Persistent Depressive Disorder given chronicity. Clinical formulation: Client's depression appears to have environmental triggers (work restructuring) coupled with genetic vulnerability (family history). Her perfectionist tendencies and difficulty setting boundaries at work may contribute to stress and emotional exhaustion. Partner relationship remains a protective factor though requires attention to prevent further strain.

Initial Treatment Plan:

Recommend weekly individual psychotherapy using Cognitive Behavioral Therapy (CBT) approach to address depression. Treatment goals collaboratively established with client include: (1) Reduce depressive symptoms and improve daily functioning, (2) Develop healthy coping strategies for work stress, (3) Re-engage with previously enjoyed activities and social connections, (4) Improve communication with partner about emotional needs. Recommend psychiatric evaluation to discuss medication options as adjunct to therapy. Provided referral to Dr. Sarah Chen, psychiatrist. Client receptive to both therapy and medication evaluation. Will also discuss potential couples counseling after individual symptoms stabilize if relationship strain persists.

Next Session:

Scheduled for next Thursday at 10:00 AM for first therapy session. Client will complete PHQ-9 and GAD-7 assessment forms before session to establish baseline symptom severity. She will also begin tracking her mood daily using a simple mood log to identify patterns. Client agreed to contact psychiatrist's office this week to schedule medication evaluation.