PSYC 6253 CBT Intake Form (template)

Patient Name:

Jacqueline Jacobson (she/her) is a 24-year-old female born on May 10, 1997. She reached

out for services November 20, 2021.

Chief Complaint/Current Functioning:

Jacqueline is seeking counselling to help manage depressive symptoms. She states that “my

depression has been creeping back the last 3 months”. 3 months ago Jacqueline has had a conflict

with her closest friend, Derek, and has been feeling persistent guilt regarding her involvement.

Jacqueline has since been avoiding contact with Derek and describes a lack of social motivation.

She states that “I’m a bad person and I don’t deserve friends”. Jacqueline has been neglecting her

hygiene needs and has been limiting her showers to once a week. She also misses work

frequently and states “there is really no point anymore, things are just going to keep going

downhill”. Jacqueline has had a difficulty concentrating on tasks and describes a decrease in

memory learning skills the past 3 months. Most of her days are spent watching TV and

overeating take-out food. She describes sleeping on average 5 hours a night and feels unrested in

the mornings.

Mental Status:

Jacqueline appears to be mildly disheveled with her hair messy and clothes unkempt. Upon our

meeting Jacqueline showed poor eye contact after talking about the conflict with her friend

Derek. Jacqueline is very well spoken and holds a graduate degree in mechanical engineering.

Her affect is congruent with her mood as she appears to be depressed and shows non verbal cues

of guilt. Jacqueline does show motivation for change as she states “I really do want some help
with this”. She lacks insight regarding her cognitive rigidity and distortions and states “I know

this is all true because I feel it”.

Symptoms/Assessment:

Jacqueline describes depressive symptoms such as anergia, anhedonia, insomnia, over eating,

and poor self worth. She scored 17 on the PHQ-9 Assessment which indicates moderately severe

depression.

Suicidal Risk to self/others:

Jacqueline denies any suicidal ideations and states “if I ever do have thoughts of hurting myself I

will let someone know right away because I know that’s serious stuff”. She denies any thoughts

or plans of hurting others.

Drug/Alcohol Issues:

Jacqueline has a history of overusing alcohol during the end of high school and towards the end

of university. She claims to have been drinking about 5 beers each evening. She has been sober

for the last two years and frequently attends Alcoholic Anonymous (AA) meetings to help

maintain sobriety. She denies any urges to drink alcohol at this time. Jacqueline denies any past

or present drug use, and states “I’ve actually never tried any drug in my life”.

Current/Past Psychological Treatment:

Jacqueline states that he has seen 3 different therapists in her life. She first seen a therapist at the

age of 16. She describes an inconsistency while attending appointments stating “I remember

missing most of my appointments”. She also describes a difficulty connecting with her past

therapists. Jacqueline has found benefit in frequently attending AA meetings and describes her

sponsor to have been a strong support the last two years.

Medical History:

Jacqueline was diagnosed with Irritable Bowel Syndrome (IBS) 3 years ago. Her IBS

symptoms have been well managed with her monthly remicade treatments. She describes an

increase in IBS symptoms the last 3 month and attributes this to overeating. Jacqueline does not

have any acute medical concerns.

Medications:

Jacqueline has trialed the antidepressants Zoloft, Paxil, and Celexa. She stopped taking

any antidepressants one year ago due to side effects. She states “I used to feel like a zombie on

those things, I also started getting anxious about things I normally wouldn’t”. Jacqueline wishes

to complete a course of CBT therapy before reconsidering medications.

Childhood history:

Jacqueline describes having a difficult childhood. Her parents divorced when she was 7

years of age and her mother was frequently verbally and sometimes physically abusive towards

her in an attempt to discipline her. She also frequently used opioids and Jacqueline recalls her

mother leaving town for months at a time to attend rehab. She describes having a good

relationship with her father and describes him as “a very level headed and genuine guy”. Her

parents had joint custody, however she would spend the majority of her childhood with her

father. She recalls a persistent feeling that she has done something wrong and often felt guilty for

disruptions in the family dynamic. Growing up she describes “feeling different than most kids”,

and chose to maintain a relationship with 3 close friends in her childhood. She recognized that

her current emotional state is most likely associated with childhood schemas.

Current Living Situation:

 Jacqueline currently lives alone in a house in the rural parts of Thunder Bay. She

describes her apartment as her “safe place” and enjoys being surrounded by nature.

Family History:

There is a history of alcoholism and drug abuse on Jacqueline’s mother’s side of the

family. Jacqueline’s grandfather died when she was young due to liver complications and her

grandmother passed away from cancer before she was born. Her mother has been diagnosed with

Borderline Personality Disorder and has been admitted to inpatient mental health services on

multiple occasions. Both of her grandparent’s remain alive on her father’s side of her family. Her

father has disclosed that he has been diagnosed with Major Depressive Disorder (MDD) but has

been managing her symptoms well with medication and psychotherapy.

Religious/Spiritual Beliefs:

Jacqueline denies any religious involvements or beliefs but does describe herself as being a very

spiritual person. She claims to have adapted the concept of a higher power from AA and has

found this very useful in maintaining her sobriety.

Work History:

Jacqueline has been working as a mechanical engineer for the last 4 years at a local engineering

firm.

Present/Past abuse:

Jacqueline has been emotionally and physically abused by her mother from a young age. She

states that she currently avoids contact with her mother because she continues to be very

accusatory and demeaning. There are no other instances of past or present abuse.

Support:
Jacqueline heavily relies on her father for emotional support. Her father also supported her

financially throughout university. She reaches out to her AA sponsor Daniel every two weeks as

an emotional support for her sobriety.

Stressors and Strengths

This worksheet template can be found in Josefowitz & Myran (2017, pg. 34-35)

Difficulties/Stressors Strengths/Areas of Reselience

Family - Unstable relationship - Strong relationship
with mom with father and
grandparents
- History of abuse from
mother - Understands positive
family values
- Family history of drug
abuse
Friends/social relationships - Avoids social contact - Has other close
friends
- Has never been
involved in romantic - Has motivation to
relationship seek romantic
relationships
- Conflict with closest
childhood friend
Recreational Activities - Is not currently - Has previously had
engaging in social many activities that
activities she did enjoy
Work or School - Missing days at work - Has previously
enjoyed work
- Confident in tasks at
work
Health - Diagnosed with IBS - No other major health
concerns
- Previously managed
IBS with diet and
treatment
Finances - Missing days from - Has a high paying job
work with good benefits
- Has built up vacation
time and sick days
 Changes - Living alone - Positive feeling of
independence
- Breakdown in
relationship with - Wants to resolve the
Derek conflict with Derek

DSM Diagnoses:

Jacqueline has been diagnosed with Major Depressive Disorder (MDD) by a Doctor in 2010

based on the DSM-5 criteria.

Goals and Treatment Plan:

The treatment goals in this section are based on the S.M.A.R.T model and the goal setting

process found in Josefowitz & Myran (2017). The treatment plan model can be found in

Zukerman (2019, pg. 342). Finally, all interventions are supported by Josefowitz & Myran

(2017). Upon our discussion Jacqueline has identified three goals for therapy. These goals and a

treatment plan can be found below.

1) Goal: To resolve guilty thoughts related to her conflict with Derek by the end of the

course of therapy.

Cognitions to change: Jacqueline shows cognitive distortions in her thought process. Some

distortions noted are mental filtering, overgeneralizing, all or nothing thinking, catastrophizing,

and predicting the future. An example of a ‘hot” thought shared is “I’m a bad person and I don’t’

deserve to have friends”.

Behaviors to change: Avoiding interpersonal relationships.

Interventions: CBT interventions can focus on the cognitive distortions and negative thinking

patterns of the client. Based on the CBT process Jacqueline must first identify and then challenge
these negative thoughts. Jacqueline can also develop coping thoughts that can help create more

positive thinking patterns. Thought records can be implemented as homework. The five factor

model can be reviewed with the client as this sense of guilt may be caused from personal

schemas and the triggering situation of the conflict with her friend. Exposure to more social

interactions can help create the necessary behavioral changes.

Observable Indicators of improvements: The frequency of negative thought patterns related to

guilty triggers can be used as a measurement for the above interventions. This could be measured

by using a thought log. Jacqueline described resolution as being able to manage guilty thought

patterns so they wont interrupt her daily life.

Expected number of visits to achieve the indicator: The collaborative goal is to resolve guilty

thoughts by the end of the treatment.

Review Date: This goal will be reviewed during each weekly session.

2) Goal: Have a shower every morning for the next week.

Cognitions to change: Thoughts of helplessness and purposelessness

Behaviors to change: Personal hygiene care.

Interventions: Behavioral activation can be used to increase the amount of activity performed by

the client, including hygiene needs. Noticing automatic thoughts of helplessness can help

manage this core belief.

Observable Indicators of improvements: A shower checklist that will be completed daily.

Expected number of visits to achieve the indicator: Jacqueline agreed that this is a reasonable

goal to complete in the first week.

Review Date: Hygiene goals will be reviewed upon each session.

3) Find 1 activity I enjoy doing by the end of the week.

Cognitions to change: Thoughts of being unable to find enjoyable activities.

Behaviors to change: Find more enjoyable activities.

Interventions: The short term goal of finding 1 enjoyable activity is based on the agenda set in

behavioral activation. Jacqueline will engage in the steps of behavioral activation to create more

positive experiences. Additionally, positive problem orientation can help create a more positive

outlook on her ability to problem solve positive activities. The understanding depression

worksheet on page 202 in Josefowitz & Myran (2017) can be provided as homework.

Observable Indicators of improvements: Indicators can be found by reviewing the understanding

depression worksheet and personal recount of a positive activity.

Expected number of visits to achieve the indicator: Jacqueline has mentioned that she has ideas

of some enjoyable activities that she can try. She predicts that she can find 1 enjoyable activity

by the end of the first week.

Review Date: Enjoyable activities can be reviewed weekly during the behavioral activation

process.

References
Josefowitz, N., & Myran, D. (2017). CBT made simple: A clinician’s guide to practicing

cognitive behavioral therapy. New Harbinger Publications, Inc.

Zuckerman, E. L. (2019). Clinician's thesaurus: The guide to conducting interviews and writing

psychological reports (8th ed.). The Guilford Press.