Trauma Initial Assessment Therapy Note Template
Description:
This template offers a structured framework for therapists conducting an initial assessment with a client who has experienced trauma. It captures essential information about the client’s trauma history, current symptoms, coping strategies, and immediate safety needs to inform a personalized treatment plan. The design emphasizes a trauma-informed approach, assessing impacts across emotional, behavioral, and relational domains while prioritizing the client’s readiness to disclose and engage.
Note:
Use this template for the first session focused on trauma-related concerns. Adapt sections based on the client’s comfort level, disclosure readiness, or specific trauma type, maintaining a sensitive and safe therapeutic environment.
Date: [Record the date of the initial trauma assessment session to mark the start 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]
Age: [Note the client’s current age to provide context for developmental and life-stage factors]
Consent and Confidentiality
[Document the client’s understanding and agreement to the therapy process, including confidentiality limits (e.g., mandatory reporting for harm), noting signatures or verbal consent per ethical guidelines for trauma work.]
Client Information
Client Name: [Enter the client’s full legal name as provided for clear record-keeping]
Date of Birth: [Record the client’s date of birth in MM/DD/YYYY format to confirm age and trauma timeline context]
Emergency Contact: [List the name, relationship, and contact information of an emergency contact for urgent situations]
Referral Source: [Note who referred the client (e.g., self, physician, crisis center) and the reason, to contextualize the assessment’s purpose]
Trauma History
Nature of Trauma: [Describe the type of trauma (e.g., physical abuse, natural disaster), as shared by the client, capturing their perspective.]
Timing and Duration: [Record when the trauma occurred, its duration, and whether it was a single event or prolonged, to establish its scope.]
Impact on Life: [Detail how the trauma affects the client’s daily functioning, relationships, or self-view, to assess its broader consequences.]
Previous Trauma Therapy: [Note any prior trauma-focused interventions, including duration, outcomes, and client feedback, to understand past treatment history.]
Current Symptoms
PTSD Symptoms: [Document trauma-related symptoms like flashbacks, nightmares, or avoidance, including frequency and severity, to evaluate for PTSD or related conditions.]
Emotional Dysregulation: [Describe the client’s emotional state, such as mood swings or dissociation, to assess their emotional processing capacity.]
Behavioral Observations: [Record in-session behaviors (e.g., fidgeting, tearfulness) to provide a snapshot of trauma-related distress.]
Functional Impairment: [Note how symptoms disrupt daily life (e.g., work, social connections), to gauge the extent of impact.]
Coping Mechanisms and Support
Current Coping Strategies: [List the client’s methods for managing symptoms (e.g., exercise, isolation), including effectiveness, to identify adaptive or maladaptive responses.]
Support Systems: [Detail available supports (e.g., family, community groups), including their role in recovery, to assess external resources.]
Risk Assessment
Self-Harm or Suicidal Ideation: [Document thoughts, plans, or actions related to self-harm or suicide, including triggers, to prioritize safety.]
Substance Use: [Note current use of alcohol, drugs, or medications, including amounts and frequency, to evaluate their role in coping.]
Protective Factors: [Identify factors reducing risk (e.g., support network, hope), to leverage in stabilization.]
Strengths and Resources
Client Strengths: [Highlight resilience, skills, or positive traits (e.g., perseverance), to identify assets for recovery.]
Interests and Supports: [List hobbies, passions, or supportive relationships, to use as coping tools or motivation.]
Goals for Therapy
Client Goals: [Describe the client’s hopes for therapy related to trauma (e.g., “feel less afraid”), capturing their priorities.]
Therapist’s Initial Goals: [Outline preliminary objectives (e.g., symptom reduction), to set a treatment direction.]
Next Steps
[Detail proposed session frequency and format (e.g., weekly in-person), initial focus (e.g., safety skills), and contact options, to establish a clear plan.]
Summary and Initial Impressions
[Summarize the therapist’s understanding of the client’s trauma presentation, integrating symptoms, coping, and strengths, to guide diagnosis and therapy.]
Plan for Treatment
[Outline the preliminary treatment approach (e.g., CBT, EMDR), focus areas (e.g., stabilization), or immediate actions (e.g., safety planning), to initiate recovery.]
Trauma Initial Assessment Therapy Note Template (Filled Mock Template)
Date: February 25, 2025
Client Name: Emily Rodriguez
Therapist Name: Dr. Sarah Thompson, LCSW
Age: 28
Consent and Confidentiality
Emily signed the consent form, agreeing to therapy and understanding confidentiality limits (e.g., harm reporting). She seemed nervous but eager to start.
Client Name: Emily Rodriguez
Date of Birth: 07/14/1996
Emergency Contact: Maria Lopez, Sister, 555-123-4567
Referral Source: Self-referred after a panic attack triggered by a news story about an assault.
Trauma History
Nature of Trauma: Sexual assault by an acquaintance
Timing and Duration: Occurred 18 months ago, a single event lasting about 30 minutes
Impact on Life: Emily reports distrust of others, especially men, and avoids social settings. She feels “tainted” and struggles with intimacy.
Previous Trauma Therapy: Attended 4 counseling sessions post-assault but stopped, feeling “too raw” to continue.
Current Symptoms
PTSD Symptoms: Flashbacks 2-3 times weekly, nightmares 1-2 times weekly, avoids crowds, hypervigilant in public
Emotional Dysregulation: Intense anger, sadness, and guilt; dissociates (“blanks out”) under stress
Behavioral Observations: Emily was anxious, and teared up occasionally, but stayed engaged and articulate.
Functional Impairment: Quit her waitressing job due to panic attacks, lost friendships, and neglects self-care (e.g., forgets to eat).
Coping Mechanisms and Support
Current Coping Strategies: Uses deep breathing, journaling, and a survivor support group; drinks wine “to relax” 3-4 nights weekly.
Support Systems: Relies on her sister Maria and finds comfort in her church community.
Risk Assessment
Self-Harm or Suicidal Ideation: Denies current thoughts but had passive ideation (“better off gone”) a month ago.
Substance Use: Drinks 1-2 glasses of wine 3-4 nights weekly; no other substances.
Protective Factors: Close sisterly bond, faith, and motivation to heal.
Strengths and Resources
Client Strengths: Reflective, resilient, and determined; draws strength from faith and group support.
Interests and Supports: Loves poetry, church activities, and nature walks.
Goals for Therapy
Client Goals: “Stop the flashbacks,” “Feel safe again,” and “Trust people.”
Therapist’s Initial Goals: Reduce PTSD symptoms, enhance emotional regulation, and build safety.
Next Steps
Weekly 60-minute sessions starting March 4, Tuesdays at 2 p.m. Initial focus on grounding skills. Contact: sarah.thompson@therapy.org or 555-987-6543.
Summary and Initial Impressions
Emily, a 28-year-old woman, presents with PTSD from a sexual assault 18 months ago. She shows notable symptoms but also strengths like support and resilience. Stabilization is the priority.
Plan for Treatment
Start with Trauma-Focused CBT for PTSD, teach safety skills, and monitor wine use. Consider EMDR later. Refer to a psychiatrist if symptoms persist.