AI Intake Assessment for Counselors Using SimplePractice

INITIAL PSYCHIATRIC/PSYCHOLOGICAL EVALUATION IDENTIFYING INFORMATION: Adult patient presenting for initial evaluation. Self-referred. CHIEF COMPLAINT: "I can't stop worrying about everything" HISTORY OF PRESENT ILLNESS: Patient describes 6+ months of persistent worry across multiple domains including work performance, health, financial stability, and relationships. Reports difficulty controlling worry despite attempts to "think positively." Associated symptoms include restlessness, fatigue, difficulty concentrating, irritability, muscle tension (particularly neck and shoulders), and sleep disturbance (difficulty falling asleep, taking 45-60 minutes most nights). Symptoms causing significant distress and impairment in occupational functioning, reporting decreased productivity and two missed deadlines. No precipitating event identified; reports gradual onset. PSYCHIATRIC HISTORY: No prior psychiatric hospitalizations. Previous outpatient treatment 2019-2020 for depression following job loss. Trial of Lexapro 10mg with partial response; discontinued after 6 months due to sexual side effects. No history of suicide attempts or self-harm. SUBSTANCE USE: Alcohol: 2-3 drinks weekly, social use, denies increased use Cannabis: Denies Other substances: Denies MEDICAL HISTORY: Hypothyroidism (controlled on levothyroxine) No other significant medical conditions Allergies: NKDA FAMILY PSYCHIATRIC HISTORY: Mother: Anxiety disorder, treated with therapy Father: No known psychiatric history Sibling: Depression SOCIAL HISTORY: Employed full-time as marketing manager. Lives with partner of 3 years. Support system includes partner and close friends. No children. College graduate. MENTAL STATUS EXAMINATION: Appearance: Well-groomed, appropriate dress for season Behavior: Cooperative, good eye contact, mild psychomotor restlessness Speech: Normal rate, rhythm, and volume Mood: "Anxious" Affect: Mildly anxious, reactive, full range Thought Process: Linear, goal-directed, no loose associations Thought Content: Worried about work performance and health; no SI/HI, no psychotic symptoms, no obsessions Perceptions: No hallucinations reported or observed Cognition: Alert, oriented x4, memory intact, concentration mildly impaired by anxiety Insight: Good Judgment: Good RISK ASSESSMENT: Suicide risk: Low (no SI, no plan, no history, protective factors present) Violence risk: Low (no HI, no history) DIAGNOSTIC IMPRESSION: Generalized Anxiety Disorder (F41.1) Rule out Major Depressive Disorder, recurrent (some overlapping symptoms) RECOMMENDATIONS: 1. Weekly individual psychotherapy - CBT approach 2. Consider medication evaluation if therapy alone insufficient after 6-8 weeks 3. Sleep hygiene education 4. Relaxation training 5. Follow up in 1 week for first therapy session