BOX6-2 Sample Intake Report
Name:MORTON, Charles (fictitious name)
Age: 22
Sex:Male
Occupation:Student
Date of interview:June 1, 1998
Therapist:Luke Baldry, Ph.D. (fictitious name)
Identifying Information:The client is a 22-year-old White
male who is presently a full-time student at a large
midwestern university. Currently, he lives alone in an
apartment and works part-time at a local grocery store.
Chief Complaint:The client presents to the clinic today
complaining of“depression”that reportedly has
become worse over the past 2 weeks.
History of Presenting Problem:The client reports that
he has experienced symptoms of depression“off
and on”for the past year. These symptoms include
(a) depressed mood (“feeling sad”); (b) appetite
disturbance but no significant weight loss; (c) sleep
disturbance (early morning awakening); (d) fatigue;
(e) feelings of worthlessness; and (g) difficulty concen-
trating. All of these symptoms have been present
nearly every day over the past 2 weeks.
The client reports that about 1 year ago, a long-
standing romantic relationship of 4 years ended. Fol-
lowing this breakup, the client reports, he became
increasingly withdrawn and, in addition to some of the
symptoms noted above, experienced several crying
spells.
Although his adjustment to this event became
better as time progressed, the client reports that the
breakup“shook”his confidence and led to a decrease
in the number of social activities he engaged in. Fur-
ther, he reports that he has not dated since. Last
semester, the client transferred to this university from
a community college in another midwestern location.
He reports that the move was difficult both emotion-
ally and academically. Specifically, being away from his
hometown, family, and friends has led him to feel
more isolated and dysphoric. Further, his grades this
past semester reportedly suffered. He reports that his
grades dropped from A’s at his previous school to C’sat
this university. Toward the end of this past semester
(once his probable grades in his classes became appar-
ent), he developed an increasing number of depressive
symptoms.
Past Treatment History:The client reports that he has
not previously sought out psychological or psychiatric
treatment.
Medical History:No significant medical history was
reported.
Substance Use/Abuse:The client denies any current
symptoms of substance abuse or dependence. He has
“tried”marijuana on three occasions in the past but
denies current use. He reports drinking, on average,
three or four cans of beer per week.
Medication:The client reports that he is not currently
taking any medication.
Family History:Both of the client’s biological parents
are living, and he has one brother (age 20) and one
sister (age 26). The client reports that his mother suf-
fers from depression and has received outpatient
treatment on numerous occasions. Further, he reports
that his maternal grandfather was diagnosed with
depression. No substance use problems among family
members were noted.
Suicidal/Homicidal Ideation:The client denied any current
or past suicidal or homicidal ideation, intent, or action.
Mental Status:The client was well-groomed, coopera-
tive, and dressed appropriately. He was alert and ori-
ented in all spheres. His mood and affect were
dysphoric. His speech was clear, coherent, and goal-
directed. Some attention and concentration difficulties
were noted. Further, his immediate memory was mildly
impaired. No evidence of formal thought disorder,
delusions, hallucinations, or suicidal/homicidal ideation
was found. His insight and judgment appear to be fair.
Diagnostic Impression
Axis I: 296.22, Major Depressive Disorder, Single
Episode
Axis II: V71.09, No Diagnosis
Axis III: None
Axis IV: Problems related to the social environment;
Educational problems
Axis V: GAF 55 (current)
Recommendations:Individual psychotherapy.
Cognitive-behavioral treatment for depression.Luke Baldry, Ph.D.
Licensed Clinical PsychologistTHE ASSESSMENT INTERVIEW 175