Headings
Identifying information · Reason for referral · Presenting problem · History of the presenting problem · Psychiatric history · Medical history · Substance use · Family history · Social and developmental history · Mental status exam · Risk assessment · Diagnostic impression · Plan
When to use it
Use it for the first one or two sessions with a new client, before any treatment starts. It gathers the whole picture in one place: symptoms, history, health, substances, family and social context, plus a mental status exam and risk screen. Unlike a progress note, it ends in a working diagnosis and the plan every later note builds on.
Example
Fictional example
Identifying information
D.K., 42, married father of two, works as a project manager. Self-referred after an urgent care visit.
Presenting problem
Four panic attacks in six weeks since a promotion. Chest tightness, shaking and fear of dying. Now avoids the office elevator and big meetings.
Substance use
Two to three beers most nights to “wind down,” up from weekends only. No other substances. Four coffees a day.
Mental status exam
Well groomed, restless, good eye contact. Mood “on edge,” affect anxious. Thought process logical. No perceptual disturbance.
Risk assessment
Denies suicidal or homicidal ideation, past or present. No firearms at home.
Diagnostic impression
Panic disorder. Rule out alcohol use disorder, mild.
Plan
Weekly CBT for panic. Complete AUDIT and PDSS at next visit. Discussed cutting caffeine.