The first-session record

Why the first note looks different.

In one sentence

A first session captures the client’s story and background, not a plan yet.

What it covers

The first time you meet someone, you’re gathering their history — why they came, the story so far, family and life context, and how they seem today.

There’s no treatment plan yet. That comes once you understand the picture, over the next session or two.

First-session record · Intake noteThe fuller write-up you make the first time you meet a client — their story, background, and how they seem right now.
Why they came · Presenting concernsThe main problem or reason the client reached out, in simple terms.
The story so far · History of present illnessHow this difficulty started and changed over time — when it began, what makes it better or worse, how bad it gets.
How they seemed today · Mental status exam (MSE)A snapshot of the client in the room — how they looked, their mood, the way they spoke, and how clear their thinking was.
Your early thinking · Working hypothesisA first, gentle guess at what may be going on — not a final diagnosis, just a direction to explore.

Why the first note looks different.

In one sentence

A first session captures the client’s story and background, not a plan yet.

The first time you meet someone, you’re gathering their history — why they came, the story so far, family and life context, and how they seem today.

There’s no treatment plan yet. That comes once you understand the picture, over the next session or two.

First-session record · Intake noteThe fuller write-up you make the first time you meet a client — their story, background, and how they seem right now.
Why they came · Presenting concernsThe main problem or reason the client reached out, in simple terms.
The story so far · History of present illnessHow this difficulty started and changed over time — when it began, what makes it better or worse, how bad it gets.
How they seemed today · Mental status exam (MSE)A snapshot of the client in the room — how they looked, their mood, the way they spoke, and how clear their thinking was.
Your early thinking · Working hypothesisA first, gentle guess at what may be going on — not a final diagnosis, just a direction to explore.