Individual Therapy Assessment

 
Individual therapy takes place between a mental health professional and a person who is seeking professional help for personal problems. Some individuals will present with specific symptoms and others might have multiple symptoms for which they are seeking help. The therapist will initiate the first session with an assessment to determine what the individual would like help with. The conversation will be open ended and the individual is free to share whatever they wish. The therapist may direct the conversation to such areas as childhood experiences or current living situations, to learn about the individual’s frame of reference.

On occasion, the individual has been referred by an outside party to attend therapy. This can include court-mandated therapy or a referral from a medical professional. However, the individual is referred, or if it is a self-initiated event, the therapist will address the referral.

For example, many medical professionals such as doctors or nurse practitioners, may refer a patient to therapy because the patient has disclosed a problem that warrants further attention. The medical professional might also be concerned because the patient disclosed drug or alcohol use that appears to be problematic.

During the first session, the therapist will address the referral and ensure that the individual is clear on the laws of confidentiality. The therapist will also provide informed consent, outlining what therapy is and is not and what the individual can expect during sessions.

If an individual was referred by a medical professional, the therapist will want to ask questions related to the physical symptoms experienced. For example, a medical doctor might refer a patient to individual therapy because the doctor wants the person to cut down on their drinking. The therapist will address this during the assessment time permitting and if not, will review in later sessions. The individual may provide information related to their drinking behavior or they may not. Sometimes the individual will minimize the drinking behavior and wish to talk about another problem. The therapist will address this during assessment.

The individual may want to address other co-occurring issues such as depression or family problems during the assessment and not talk about why the doctor referred them for therapy. This will need to be noted by the therapist as there may be underlying issues that need to be addressed. It will be important for the therapist to ascertain why the individual minimizes the drinking and prefers to work on other problems.