ADHD Initial Assessment Therapy Note Template
Description:
This template provides a structured framework for therapists conducting an initial assessment session with a client presenting with possible or confirmed ADHD, capturing essential information about symptoms, history, and current functioning to inform diagnosis and treatment planning. It is designed to evaluate ADHD-specific characteristics across developmental stages and contexts, with detailed guidance within brackets to ensure a thorough, evidence-based assessment that supports tailored therapeutic intervention.
Note:
This template is intended for the first session assessing ADHD concerns. Adapt sections based on the client’s age (child, adolescent, adult), symptom presentation, or available collateral information, ensuring sensitivity to their engagement level and comprehension.
Date: [Record the date of the initial ADHD assessment session to establish the starting point of the client’s therapeutic record]
Client Name: [Enter the client’s full legal name for accurate identification and documentation]
Therapist Name: [Enter the therapist’s full name to establish accountability and authorship of the assessment]
Age: [Note the client’s current age to provide context for developmental expectations and ADHD symptom interpretation]
Consent and Confidentiality
[Document the client’s (or caregiver’s, if a minor) understanding and agreement to the assessment process, including confidentiality limits (e.g., mandatory reporting for harm), noting signatures or verbal consent as required by practice standards and legal guidelines.]
Client Information
Client Name: [Enter the client’s full legal name as provided, ensuring clarity for record-keeping and identification]
Date of Birth: [Record the client’s date of birth in MM/DD/YYYY format to confirm their exact age and developmental stage]
Caregiver(s) or Emergency Contact: [List the names, relationships (e.g., parent, spouse), and contact information of primary caregivers or emergency contacts, to identify key supports or informants for the assessment]
Referral Source: [Note who referred the client for ADHD assessment (e.g., self, physician, school), including reason for referral, to contextualize the evaluation’s origin]
Presenting Problem & History
Reason for Assessment: [Describe the primary concerns prompting the ADHD evaluation, as reported by the client, caregiver, or referrer, capturing specific symptoms like inattention or impulsivity in their own words.]
Onset and Duration: [Record when ADHD-related symptoms first emerged, how long they have persisted, and any changes over time, to establish a developmental timeline and chronicity of the issues.]
Developmental History: [Detail the client’s early developmental milestones (e.g., speech, motor skills), any delays, or significant events (e.g., trauma), to assess how developmental factors may relate to ADHD symptoms.]
ADHD Symptom History: [List past and current ADHD symptoms (e.g., inattention, hyperactivity, impulsivity) across settings (home, school, work), referencing DSM-5 criteria, to evaluate symptom presence and severity over time.]
Mental Health/Medical History: [Note any past or current mental health diagnoses (e.g., anxiety, depression), medical conditions, or medications, including dates and relevance to ADHD, to identify comorbidities or differential diagnoses.]
Current Functioning
Inattention Symptoms: [Describe current examples of inattention reported or observed (e.g., difficulty sustaining focus, forgetfulness), including frequency and impact, to assess this core ADHD domain.]
Hyperactivity/Impulsivity Symptoms: [Record current examples of hyperactivity or impulsivity (e.g., fidgeting, interrupting), including frequency and impact, to evaluate this core ADHD domain.]
Behavioral Observations: [Note the client’s observable behaviors during the session, such as restlessness, distractibility, or engagement level, to provide an in-session snapshot of ADHD-related traits.]
Functional Impairment: [Detail how ADHD symptoms affect daily life (e.g., school performance, work productivity, relationships), as reported or observed, to assess the degree of disruption across contexts.]
Family and Environmental Context
Family History: [Document any family history of ADHD or related conditions (e.g., learning disorders, anxiety), specifying relatives and diagnoses, to explore genetic or environmental influences.]
Current Environment: [Describe the client’s living situation, school/work setting, or social context, including stressors or supports, to understand environmental factors impacting ADHD symptoms.]
Caregiver/Collateral Input: [Record observations from caregivers, teachers, or significant others about the client’s symptoms and functioning, to supplement the client’s self-report with external perspectives.]
Risk Assessment
[Document any reported or observed risks associated with ADHD, such as impulsivity leading to accidents, substance use, or emotional dysregulation causing self-harm thoughts, including severity and protective factors, to prioritize safety in the treatment plan.]
Strengths and Resources
Client Strengths: [Highlight the client’s positive attributes or skills (e.g., creativity, resilience), to identify assets that can support ADHD management and therapy engagement.]
Interests and Supports: [List the client’s hobbies, passions, or supportive relationships (e.g., sports, friends), to leverage as coping tools or motivational factors in treatment.]
Goals for Therapy
Client Goals: [Describe what the client hopes to achieve through therapy related to ADHD (e.g., “focus better”), capturing their personal priorities or desired changes.]
Caregiver Goals (if applicable): [Note what caregivers or significant others hope the client will achieve, if involved, to align family expectations with treatment.]
Therapist’s Initial Goals: [Outline preliminary therapeutic objectives based on the assessment, such as improving attention or reducing impulsivity, to set a direction for ADHD-focused intervention.]
Next Steps
[Detail the proposed frequency and format of future sessions (e.g., weekly therapy, caregiver involvement), what to expect initially (e.g., psychoeducation), and how the client or caregivers can contact the therapist, to establish a clear plan and communication pathway.]
Summary and Initial Impressions
[Summarize the therapist’s initial understanding of the client’s ADHD presentation, integrating symptom profile, impairments, and strengths, to provide a cohesive overview for guiding diagnosis and therapy.]
Plan for Treatment
[Outline the preliminary treatment approach, including potential modalities (e.g., behavioral therapy, CBT), focus areas (e.g., executive functioning skills), or immediate actions (e.g., referral for medication evaluation), to initiate a tailored ADHD management plan.]
ADHD Initial Assessment Therapy Note Template (Filled Mock Sessions)
Date: February 25, 2025
Client Name: Ethan Carter
Therapist Name: Dr. Lisa Morgan, LPC
Age: 32
Consent and Confidentiality
Ethan signed the consent form, agreeing to the ADHD assessment and understanding confidentiality limits (e.g., reporting harm). He expressed eagerness to “figure this out.”
Client Information
Client Name: Ethan Carter
Date of Birth: 11/03/1992
Caregiver(s) or Emergency Contact: Jessica Carter, Wife, 555-678-9012
Referral Source: Self-referred after reading about ADHD online, suspecting it explains lifelong “chaos” at work and home.
Presenting Problem & History
Reason for Assessment: Ethan reports “ CONSTANT distraction” and “messing up everything,” saying, “I can’t keep my life together—work’s a disaster, and my wife’s fed up.”
Onset and Duration: Symptoms present since childhood (e.g., “always in trouble at school”), worsening in adulthood with job demands over the past 5 years.
Developmental History: Met milestones on time (walking at 13 months, talking by 2 years). Struggled academically from grade 3, labeled “lazy” by teachers.
ADHD Symptom History: Childhood: hyperactivity (running in class), inattention (lost homework). Adulthood: forgets deadlines, interrupts others, fidgets constantly.
Mental Health/Medical History: Diagnosed with anxiety in 2018, takes lorazepam PRN (rarely). No chronic medical issues.
Inattention Symptoms: Misses work meetings, loses keys daily, drifts off mid-conversation (5-6 times/week), causing friction with wife and boss.
Hyperactivity/Impulsivity Symptoms: Fidgets with pen in-session, blurts out answers, makes impulsive purchases (e.g., $200 gadget last week).
Behavioral Observations: Ethan shifted in his seat, tapped foot rapidly, but maintained focus when redirected. Laughed nervously often.
Functional Impairment: Job at risk (written warning last month), wife threatens separation due to unreliability, forgets bills despite reminders.
Family History: Father likely had undiagnosed ADHD (disorganized, impulsive). Sister has anxiety. No other known conditions.
Current Environment: Lives with wife in a condo, works as a sales rep (high-pressure role). Cluttered home adds to stress.
Caregiver/Collateral Input: Wife Jessica says, “He’s brilliant but can’t follow through—drives me crazy.” Confirms lifelong pattern.
No suicidal ideation or self-harm. Impulsivity led to a minor car accident last year (rear-ended someone). Protective factors: wife’s support, job motivation.
Client Strengths: Creative problem-solver, quick-witted, persistent despite setbacks—kept job 3 years despite struggles.
Interests and Supports: Enjoys gaming, hiking with wife. Relies on Jessica and a close friend for reminders.
Client Goals: Ethan wants to “focus at work and not let Jessica down—I hate feeling like a failure.”
Caregiver Goals (if applicable): Jessica hopes he’ll “get organized and be present at home.”
Therapist’s Initial Goals: Improve attention regulation, develop organizational skills, reduce relational strain.
Weekly 50-minute sessions starting March 4, Tuesdays at 4 p.m. Initial focus on psychoeducation about ADHD. Ethan can email lisa.morgan@therapy.org or call 555-345-6789.
Ethan is a 32-year-old man with lifelong ADHD symptoms (inattention, impulsivity) severely impacting work and marriage. Strengths include creativity and support system, but executive dysfunction is a core challenge.
Start with CBT to build task management skills, introduce a daily planner system, and refer to a psychiatrist for ADHD medication evaluation.