Intake Note

Intake Overview

The client self-referred for anxiety, low mood and sleep disruption that had developed over five months while taking on increased caring responsibilities for their mother. Distress was affecting concentration at work, social contact and rest. Initial measures were in the moderate range for anxiety and depressive symptoms, direct risk assessment did not identify a current concern, and a preliminary formulation focused on caregiving strain, high responsibility and reduced recovery time. The client and therapist agreed to begin a short course of fortnightly integrative therapy with an early review.

Referral, Intake and Consent

The client self-referred after discussing stress with their GP. The therapist explained the nature of the service, confidentiality and its limits, record keeping, fees and cancellation arrangements. The client asked how information would be shared with the GP, agreed that contact would occur only with their consent unless a safety or legal exception applied, and gave verbal consent to proceed with the assessment.

Presenting Concerns and History of Presenting Concerns

The client reported increasing worry, guilt and low mood since their mother required regular practical support following a stroke five months earlier. They described difficulty switching off from possible problems, delayed sleep on most work nights, reduced enjoyment and episodes of tearfulness when feeling unable to meet both work and family expectations. Symptoms had intensified during the previous six weeks as appointments and household tasks increased. The client wanted help reducing guilt, setting sustainable limits and recovering a sense of life outside caring responsibilities.

Current Functioning and Context

The client continued working four days per week as a project coordinator but reported reduced concentration and staying late to compensate. Sleep averaged five to six hours, with prolonged settling and early waking twice weekly; appetite was less regular on busy days. The client had stopped weekly swimming and was declining most evening invitations because of fatigue. Their sister provided some weekend support, although the client found it difficult to ask for additional help. Their manager had agreed to temporary flexibility for medical appointments involving the client’s mother.

Relevant Personal, Developmental, Family and Social History

The client described growing up in a family where being dependable and managing practical problems were strongly valued. They recalled taking on additional household responsibilities during a period of parental illness in adolescence and associated this with their current discomfort asking others for help. The therapist treated this as a possible formulation link rather than an established cause. The client described a supportive relationship with their sister and several friendships that had become less active during the recent caring period.

Mental Health and Treatment History

The client reported four sessions of university counselling for examination stress approximately eight years earlier, which they found helpful for organising routines. They denied previous psychiatric admission, crisis-team involvement or a clinician-given mental-health diagnosis when these areas were reviewed. No previous structured psychotherapy was reported.

Medical History, Medication and Substance Use

The client reported episodic migraine treated with prescribed sumatriptan as needed and no current psychotropic medication. They described drinking two to three units of alcohol across a typical week and denied use of non-prescribed drugs when asked. The client reported no current concern about medication or substance use.

Mental State Examination / Behavioural Observations

The therapist documented that the client was appropriately dressed, with clear speech at a normal rate and logical, goal-directed thought form. The client described their mood as overwhelmed and low; the therapist observed a subdued but responsive affect during discussion of caring pressures. No perceptual disturbance was reported during direct review.

Assessment and Measures

The client completed the PHQ-9 and GAD-7 during the assessment, scoring 12 and 11 respectively. The therapist interpreted both scores as falling within the moderate range and used them as baseline indicators to review alongside functioning and the client’s stated goals rather than as diagnostic evidence.

Risk Assessment, Safeguarding and Protective Factors

The therapist directly assessed current and historical suicidal thoughts, self-harm and thoughts of harming others. The client denied all three, including plan or intent, and identified their sister, a close friend and their GP as people they would contact if distress increased.

Diagnostic Status and Working Formulation

The therapist did not make a formal diagnosis at this assessment and described anxiety and low mood in the context of caregiving strain as a preliminary clinical understanding. Possible precipitating factors included the mother’s increased support needs and recent escalation in appointments. Supported perpetuating processes included high responsibility, difficulty requesting help, reduced restorative activity, overworking and disrupted sleep. Protective resources included a supportive sister and manager, retained employment, previous benefit from counselling and active help-seeking. The client agreed that this formulation broadly fitted while wanting further exploration of how family expectations shaped guilt.

Goals, Preferences and Proposed Treatment Plan

The client prioritised improving sleep, responding differently to guilt, sharing caring tasks more sustainably and resuming one restorative activity. The therapist proposed integrative therapy drawing initially on formulation, boundary work and behavioural re-engagement, with six fortnightly sessions and a review after the third. The client agreed with this provisional plan and asked for practical between-session steps alongside exploration of family responsibility.

Coordination and Next Steps

• Assessment or treatment focus for next session: Refine the maintaining formulation and identify an initial boundary and recovery target.

• Client action before next session: The client agreed to note occasions when they considered asking for help, including the anticipated consequence and what they did.

• Booking, timing or frequency arrangements: The next fortnightly session was booked for the agreed time.