Relationship Therapy Intake Assessment (US)
Assessment Session Template:
A standard relationship therapy intake assessment that can be used to support CPT code 90847 or 90791 for initial couples therapy evaluations by licensed mental health professionals. It may be used flexibly with separable framing around the primary client (determined by the client name or specified by the clinician) and partner (secondary client) for individualized intake and diagnostic components in addition to the couples’ perspective. This includes presenting concerns, clinical, family, relationship, and social history, risk assessment, MSE, clinical assessments where administered, clinical summary/diagnosis(es), treatment goals with plan, and clinical recommendations, and may be used for insurance billing purposes.
For ongoing couples therapy sessions, consider using the companion Couples Therapy Progress Note template, which leverages this session and future sessions, in addition to documents including treatment plans, to connect the clinical narrative. Use these templates in NovoNote, NovoPsych’s AI scribe for mental health clinicians.
Primary Client: the person named in the client line or by the clinician
Partner (Secondary Client): the second partner
Setting/Modality: In person or telehealth
Location: Where each partner attended from and if they were in same location
Consent and Confidentiality: Informed consent for evaluation and treatment, telehealth consent and any release of information, recorded for each partner where discussed
Demographics
- Primary client: age, gender identity, sexual orientation, pronouns, ethnicity and preferred language as stated
- Partner (secondary client): same as above
Presenting Problem
- The couple’s presenting concern in their own words, with onset, duration, triggers and impact on the relationship
- The primary client’s symptoms as they relate to the conflict: onset, frequency, severity, current stressors and impact on daily functioning
- The partner’s report where it supports the primary client’s symptoms, then the partner’s own perspective
Relationship History
- Relationship length, commitment status, living arrangement and children
- Significant events such as separations, affairs, losses or major transitions
- Recurring conflict pattern, prior couples therapy and its outcome
- Each partner’s stated goal for the relationship
Mental Status Examination
Primary Client
- Appearance: Grooming, dress and physical presentation as observed
- Behavior: Activity level, cooperation, eye contact and any notable behaviors as observed
- Speech: Rate, rhythm, volume and tone as observed
- Mood: Patient’s reported mood, using their own words where possible
- Affect: Range, congruence and appropriateness as observed, noting any discrepancy with the stated mood
- Thought Process: Organization, coherence and goal-direction
- Thought Content: Preoccupations, delusions and intrusive thoughts, recording unwanted thoughts the patient finds distressing and rejects in the patient’s own terms
- Perception: Reported hallucinations or sensory misinterpretations, with type and impact
- Cognition: Memory, orientation, concentration and comprehension
- Insight: Patient’s understanding of their own condition and treatment
- Judgment: Decision-making ability and understanding of consequences
Partner (Secondary Client)
- Same as above
Safety and Risk Assessment
Primary Client
- Suicidal ideation: ideation, then intent, plan, means, preparatory behavior and deterrents as separate factors, and any instrument used
- Homicidal ideation and risk to others: ideation, targets, intent, plan, means
- Self-harm: current and historical non-suicidal self-injury
- Access to lethal means: firearms, medications, other means, and steps to reduce access
- Intimate partner violence and aggression: physical, sexual, emotional or coercive control, in either direction using objective brief description of behavior, or quote
- Abuse/Neglect: statements of abuse or neglect of a child, elderly, or dependent adult
- Other Risk to self: record self-neglect or impaired capacity for self-care; impulsive or risky behaviors resulting into significant threat of harm to self or to others
- Risk formulation and management: Clinician’s risk formulation, any risk level stated, steps taken this session: safety planning, means restriction, level of care, follow-up, crisis instructions, mandated report, identification of warning signs or protective factors.
Partner (Secondary Client)
- Same as above
Clinical History
Primary Client
- Psychiatric/Therapy History: prior diagnoses, therapy, hospitalizations, timeframes and how helpful
- Medical History: chronic conditions and primary care provider, if named
- Current Medications: medications, adherence, recent changes, and the prescriber where named
- Substance Use History: alcohol, cannabis, illicit drugs and nicotine, with frequency, amount and impact, for the categories asked about
- Family Psychiatric History: mental health conditions, substance use or suicide in relatives, and family-of-origin patterns relevant to session content/presenting problem(s)
- Trauma History: trauma exposure, timing, impact and coping, and any link to relationship concerns or presenting problems
- Social History: living situation, finances, parenting, work, education, supports, legal, spiritual and cultural context.
Partner (Secondary Client)
- Same as above
Clinical Assessments
- Brief interpretation of scores
- Summary of Scores table: Measure, Informant, Domain, Score and Severity Band
Clinical Assessment Summary
- Diagnostic impression and conceptualization centered on the primary client
- Symptoms, observed behaviors, interpersonal patterns, cultural, social and family factors, and role of relationship conflict and symptoms in maintenance/worsening of problems
- Risk factors and functional impairment
- DSM-5-TR diagnosis with ICD-10-CM code where evidenced, including Relationship Distress With Spouse or Intimate Partner (Z63.0) where supported
- Medical necessity and any rule-outs raised by the clinician
Treatment Plan and Recommendations
- Recommended modality: couples therapy plus any additional therapy or change in level of care
- Frequency: weekly, biweekly or as needed
- Initial treatment goals and plan: numbered goals labeled as primary client then couples goals, each with an objective, intervention and evidence-based approach
- Referrals provided for each partner if indicated
Primary Client: Mary Blogs
Partner (Secondary Client): Tom Blogs
Setting/Modality: In person
Location: Both partners attended together at 11 NovoNote Street, Suite 200, Austin, TX 78701.
Consent and Confidentiality: Mary and Tom each gave informed consent for evaluation and couples treatment. The clinician explained the limits of confidentiality. No release of information was discussed.
Demographics
- Mary: 42 years old; woman; she/her; heterosexual; White; English
- Tom: 44 years old; man; he/him; heterosexual; White; English
Presenting Problem
Mary and Tom presented for couples therapy after 14 years of marriage, describing “constant arguing” and growing distance over the past year. Conflict escalated after Tom’s job loss eight months ago, with frequent arguments about finances and household roles that Mary said leave them “living like roommates.”
Mary reports low mood, poor sleep and tearfulness most days for about six months, with reduced concentration at work and withdrawal from friends. Tom agreed Mary “hasn’t been herself” and has stopped joining family outings. Tom reports feeling criticized and “shut out,” and describes worry about money and finding new work.
Relationship History
Mary and Tom met at work, married in 2012 and live together with their two children, aged 10 and 7. Tom’s job loss and the death of Mary’s father last year are significant recent stressors. Their recurring pattern is Mary raising concerns and Tom withdrawing, with arguments ending in days of silence. They attended three sessions of couples counseling in 2019, which Mary found “somewhat helpful.” Both want to stay together; Mary wants to “feel like a team again,” and Tom wants “less fighting.”
Mental Status Examination
Primary Client – Mary
- Appearance: Casually dressed, well groomed
- Behavior: Cooperative, good eye contact, tearful at times
- Speech: Normal rate and volume, soft tone
- Mood: “Exhausted and sad”
- Affect: Constricted, congruent with mood
- Thought Process: Linear and goal-directed
- Thought Content: Preoccupied with finances and the marriage; no delusions
- Perception: No hallucinations reported
- Cognition: Alert and oriented; reports poor concentration
- Insight: Good
- Judgment: Intact
Secondary Client – Tom
- Appearance: Casually dressed, well groomed
- Behavior: Cooperative, limited eye contact when discussing conflict
- Speech: Normal rate, volume and tone
- Mood: “Stressed”
- Affect: Restricted, mildly irritable
- Thought Process: Linear and goal-directed
- Thought Content: Preoccupied with job search; no delusions
- Perception: Not assessed
- Cognition: Not assessed
- Insight: Fair
- Judgment: Intact
Safety and Risk Assessment
Primary Client – Mary
- Suicidal ideation: Denied current or past thoughts of wanting to die, intent or plan
- Homicidal ideation and risk to others: Denied
- Self-harm: Denied current or past self-harm
- Access to lethal means: No firearms in the home
- Intimate partner violence and aggression: Both partners denied physical, sexual or coercive behavior; arguments described as “yelling, then silence”
- Abuse/Neglect: Not assessed
- Other risk to self: Not assessed
- Risk formulation and management: No formal risk level given by the clinician. Risk factors: depressive symptoms, recent bereavement and financial stress. Protective factors: her children, engagement in treatment and support from her sister. Crisis resources, including the 988 Suicide & Crisis Lifeline, were provided.
Secondary Client – Tom
- Client denied past/present safety and risk concerns.
Clinical History
Primary Client – Mary
- Psychiatric/Therapy History: Brief individual counseling after her father’s death in 2025; no prior diagnoses or hospitalizations
- Medical History: Hypothyroidism, managed by her primary care provider
- Current Medications: Levothyroxine, taken as prescribed
- Substance Use History: Two glasses of wine on weekends; denied other substance use
- Family Psychiatric History: Mother treated for depression
- Trauma History: Not discussed or reported
- Social History: Works full time as a teacher; supportive sister nearby; reduced contact with friends
Secondary Client – Tom
- Psychiatric/Therapy History: Denied prior mental health treatment
- Medical History: Not discussed or reported
- Current Medications: None
- Substance Use History: Three to four beers most weekends; denied other substance use
- Family Psychiatric History: Father had alcohol use problems
- Trauma History: Not discussed or reported
- Social History: Laid off as a project manager eight months ago and actively job searching; few close supports outside the family
Clinical Assessments
Mary’s scores indicate moderate depression and mild anxiety. Both partners’ scores fall in the distressed range for relationship satisfaction.
Summary of Scores
| Measure | Informant | Domain | Score | Severity Band |
| PHQ-9 | Mary | Depression | 14 | Moderate |
| GAD-7 | Mary | Anxiety | 7 | Mild |
| CSI-16 | Mary | Relationship satisfaction | 38 | Distressed |
| CSI-16 | Tom | Relationship satisfaction | 45 | Distressed |
Clinical Assessment Summary
Mary presents with six months of low mood, poor sleep, tearfulness, poor concentration and social withdrawal, consistent with her moderate PHQ-9 score. Her symptoms began after her father’s death and are maintained by a pursue-withdraw cycle with Tom that intensified after his job loss, leaving her feeling unsupported. The relationship conflict and her low mood appear to reinforce each other, with Tom’s withdrawal and financial worry adding to the strain. Functional impact includes reduced concentration at work and withdrawal from friends and family activities. Diagnostic impression: Major Depressive Disorder, Single Episode, Moderate (F32.1), and Relationship Distress With Spouse or Intimate Partner (Z63.0). Medical necessity is supported by clinically significant depressive symptoms and relationship distress with functional impairment; the clinician raised prolonged grief disorder as a rule-out.
Treatment Plan and Recommendations
Recommended Modality: Couples therapy (Emotionally Focused Therapy), with individual therapy recommended for Mary
- Frequency: Weekly
- Initial Treatment Goals and Plan:
- (Primary client goal) Reduce depressive symptoms.
Objective: Mary will schedule two pleasant activities each week and track her mood.
Intervention: Behavioral activation and PHQ-9 monitoring (CBT). - (Couples goal) “Feel like a team again.”
Objective: The couple will identify their pursue-withdraw cycle and complete one calm check-in each week.
Intervention: Map the negative cycle and build emotional responsiveness (EFT). - (Couples goal) “Less fighting.”
Objective: The couple will use time-outs and a structured conversation for financial disagreements.
Intervention: Conflict management skills training (Gottman Method).
- (Primary client goal) Reduce depressive symptoms.
- Referrals Provided: Mary – individual therapist for depression and grief; Tom – None
- Template Type
- Session Note
- Assessment Session
Author:
Dr Liz Rojas
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