Intake Assessment / First Interview Template
Opening Rapport Notes:
Mara arrived early and stayed guarded for the first ten minutes. Thanked the clinic twice for the appointment while describing how long she had put off booking it.
Presenting Concerns (in client's own words):
Reports being "flat since about April" with three episodes of sudden breathlessness she found frightening. Describes carrying a weight in her chest and having stopped the swimming and choir she used to look forward to. States "I can't switch the noise off" and "small things feel enormous now."
Emotional & Physical Symptom Check:
Low mood persisting approximately 7 months. Marked anhedonia — loss of interest in swimming, choir practice, and cooking. Panic episodes occurring 3 times in the past month with chest tightness, racing heart, and difficulty breathing, lasting 10–15 minutes with several hours of shakiness afterwards. Episodes triggered by workload spikes and unplanned social contact. Sleep disrupted, with sleep onset around 01:30 and consistent early waking at 04:10, unable to return to sleep. Appetite reduced — typically one meal a day, meals skipped through forgetting rather than intent. Persistent fatigue and low energy. Episodes of tearfulness, particularly before work.
Brief Life Context:
Works as a logistics planner but reports slipping deadlines and a recent performance conversation. Lives alone in a first-floor flat with a balcony she has stopped tending. No current partner. Two close friends check in weekly, though she cancels most plans and describes feeling embarrassed by that. Family live overseas with limited contact — has not told them about the panic episodes or the change in her sleep.