CBT Initial Assessment Therapy Note Template

Description:

This template is designed for the first session of cognitive behavioral therapy (CBT), providing a structured framework to gather essential information about the client’s presenting problem, history, current functioning, and to establish initial treatment goals and plans. It emphasizes the identification of cognitive, behavioral, and emotional patterns that are targets for intervention in CBT.

Note:

This template is intended for the initial assessment session in CBT. Adjust sections based on the client’s presentation and the specific problems being addressed, ensuring that the assessment is client-centered and collaboratively developed.

Date: [Record the date of the session]

Client Name: [Enter the client’s full legal name]

Therapist Name: [Enter the therapist’s full name]

Presenting Problem

Client’s Report: [Capture the client’s own description of why they are seeking therapy, including their main concerns or symptoms.]
Onset and Duration: [Note the approximate date or age when the problem first began, and how long it has been a significant issue for the client.]

History

Past Psychiatric History: [List any previous mental health diagnoses, the dates they were made, and any treatments received, including medications, therapy, or hospitalizations.]
Medical History: [Detail any current or past medical conditions that may be relevant to the client’s mental health, including any ongoing treatments or medications.]
Substance Use History: [Record the client’s current and past use of alcohol, drugs, or medications, including frequency, quantity, and any history of substance use disorders or treatment.]
Developmental History: [Briefly outline key developmental stages or experiences, such as early childhood, adolescence, and any significant events or trauma that may have shaped the client’s current functioning.]
Family History: [Note any family members who have experienced mental health issues, substance use problems, or other relevant conditions, and their relationship to the client.]
Social History: [Describe the client’s current living situation, marital status, occupation, educational background, and social supports, including any recent changes or stressors.]

Current Functioning

Symptoms and Behaviors: [Detail the client’s current symptoms, such as depression, anxiety, or other emotional experiences, and any specific behaviors that are problematic, including their frequency and intensity.]
Impact on Life: [Explain how these symptoms and behaviors are affecting the client’s daily life, including their ability to work, maintain relationships, and engage in leisure activities.]
Standardized Assessments: [Note any standardized scales or questionnaires administered, along with their scores and interpretations.]

Risk Assessment

Suicidal Ideation: [Note any thoughts of self-harm or suicide, including frequency, plans, and intent.]
Harm to Others: [Record any thoughts or behaviors indicating potential harm to others.]
Substance Use: [Reiterate any substance use that may pose a risk, such as heavy drinking or drug use.]
Protective Factors: [Identify any factors that reduce the risk, such as social supports, coping skills, or treatment engagement.]

CBT-Specific Assessment

Automatic Thoughts: [Identify and record specific negative or distorted thoughts that the client experiences in relation to their problem, noting any patterns or common themes.]
Core Beliefs: [Explore and note any underlying beliefs or schemas that the client holds about themselves, others, or the world, which may be contributing to their current issues.]
Behavioral Patterns: [Describe any behaviors that the client engages in that may be maintaining or worsening their problems, such as avoidance, procrastination, or other maladaptive coping strategies.]
Emotional Responses: [Identify the primary emotions associated with the client’s problem, such as fear, sadness, anger, or guilt, and note any patterns or triggers for these emotions.]

Initial Formulation

[Summarize how the client’s thoughts, behaviors, and emotions are interconnected to perpetuate the problem. This should be a brief narrative that outlines the cognitive-behavioral model specific to the client’s case.]

Goals for Therapy

Client’s Goals: [Record the client’s own stated objectives for therapy, in their own words.]
Specific, Measurable Goals: [Work collaboratively with the client to set concrete, achievable goals that can be measured over time, such as reducing symptoms, changing behaviors, or improving quality of life.]

Plan for Treatment

Therapeutic Approach: [Outline the specific CBT techniques or strategies that will be used to address the identified thoughts, behaviors, and emotions, such as cognitive restructuring, exposure therapy, behavioral activation, or relaxation training.]
Frequency and Duration: [Specify how often sessions will be held (e.g., weekly), the expected length of each session, and the anticipated duration of therapy.]
Homework or Tasks: [Assign any initial tasks or homework that the client can complete between sessions to practice new skills or gather data, such as monitoring thoughts, engaging in behavioral experiments, or practicing relaxation techniques.]

Summary and Initial Impressions

[Provide a concise summary of the session, highlighting key points from the assessment, the initial formulation, and the agreed-upon goals and plan. Also, note any initial impressions or observations that may be relevant for future sessions.]