First Therapy Session | What could it look like? Intake Example for Interns: A Ph.D. Teaches You

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Summary

A demonstration of an initial therapy intake assessment performed by a pre-licensed counselor under supervision, covering patient confidentiality, background history, and establishing treatment goals.

Highlights

Introduction and Confidentiality
00:01:17

Dr. Snow White explains the role of a pre-licensed counselor, introduces her supervisors, and outlines the limits of patient confidentiality, including instances of safety threats or abuse against minors and the elderly.

Presenting Concerns and Relationship Dynamics
00:03:28

The patient discusses her primary reason for seeking help: depression related to her husband's alcoholism, verbal abuse, and a recent incident of physical intimidation. The therapist explores the patient's emotional response and the history of these stressors.

Symptom Review and Physical Health
00:09:47

The assessment continues with a discussion of the physical impact of the stressor, including appetite changes, sleep issues, and existing medical conditions like IBS. The patient expresses concerns about her coping mechanisms, specifically excessive exercise.

Mental Health and Anxiety History
00:13:07

The patient reveals a past diagnosis of generalized anxiety from high school and describes a recent panic attack triggered by her home environment, noting that her anxiety currently affects her parenting.

Social and Medical History
00:20:12

The session covers the patient's upbringing in a chaotic home environment, her educational background as a nurse, and current financial status, while emphasizing how physical health and past traumas relate to current mental health.

Family History and Treatment Goals
00:39:07

The therapist conducts a family history review, exploring substance abuse, mental illness, and suicide within the family. The patient clarifies her goals for therapy, which include improving her marriage and finding personal happiness and safety.

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