Diagnostic Assessment Note (Marriage and Family Therapy)

Date of Service: [Date] ([Start time – End time / Total duration])

Location: [office / home-based / community site / school / other: specify]

Modality: [in-person / video / audio-only]

Provider: [Name, credentials, license type]

Participants Present: [List all attendees with relationship to identified client and role (client unit member vs. collateral/support); clearly identify the client/patient of record]

Referral Source: [self / PCP / court / school / EAP / other: specify]

Consent & Confidentiality

Informed consent: [Obtained from: names/roles; verbal or written]

Confidentiality limits: [Standard limits reviewed including safety exceptions and mandated reporting]

MFT confidentiality structure: [Who is the "client" for treatment/record access; no-secrets policy status; how individual disclosures are handled in couple/family work]

Releases of Information: [ROIs obtained or declined and purpose]

Minor consent/custody: [Legal authority for consent; assent approach] (Include only if clinically relevant.)

Identifying Information

• Name: [Identified client/patient of record]
• DOB/Age: [Date of birth / age]
• Pronouns: [if provided]
• Gender identity: [if provided]
• Household composition & key relationships: [Members, relationships, living arrangements]
• Employment/School status: [Role, grade/level, schedule]
• Primary language: [Language and interpreter needs]
• Cultural/Ethnic identity: [Self-described if client chooses to share]
• Emergency contact: [Name, relationship, phone]

Presenting Concerns & History of Present Illness

Chief concern: "[Client's words]"

[Current problems: onset, duration, frequency, severity, and course]

[Functional impact on relationships, parenting, work/school, sleep, and daily functioning]

[Systemic context: relationship dynamics, conflict cycles, co-parenting stress, boundary issues, relevant stressors] (When participants' accounts differ, document parallel perspectives without selecting a single version.)

[Prior coping attempts and treatment history]

Client goals for treatment: [Goals stated by client/family]

Psychosocial History

(If a domain is clinically relevant but not assessed, note "not assessed today" with brief reason.)

• Behavioral Health History: [Prior diagnoses; psychotherapy type/duration/outcomes; hospitalizations; prior self-harm/suicide history and safety planning; prior couple/family therapy]
• Medical History: [Relevant medical conditions, chronic pain, sleep disorders, head injuries; current medications including psychotropics and adherence]
• Substance Use: [Alcohol, cannabis, nicotine, other substances; pattern/trajectory; relation to conflict/violence risk or parenting; recovery supports and prior treatment]
• Trauma & Safety History: [Relevant trauma exposure; current/past IPV or coercive control; child safety concerns; legal involvement] (Avoid forcing detail on trauma.)
• Developmental & Relational History: [Family of origin and attachment; significant relationship history; marriage/commitment timeline; parenting history]
• Social Context: [Housing, finances, employment stability; social supports; community/faith resources; legal/immigration stressors; cultural factors affecting help-seeking]
• Strengths & Protective Factors: [Individual strengths, relational strengths, environmental supports]

Family Systems Assessment

• Family Structure: [Household members, caregiving roles, custody/visitation schedules, extended family involvement]
• Relational Patterns: [Typical conflict sequence (trigger → escalation → repair/withdrawal → aftermath); communication patterns; boundaries, alliances, roles]
• Genogram Summary: [Clinically relevant intergenerational themes] (Include only if completed.)
• Cultural/Systemic Context: [Cultural values about marriage/family, gender roles, parenting norms, minority stress]
• Change Readiness: [Motivation and stage of change for each participating adult]

Systemic Hypothesis: [Clinician's formulation of how interaction cycles and contextual factors maintain the presenting problems]

Mental Status Examination

(For other participants, include brief behavioral observations only. For children, use developmentally appropriate observations.)

• Appearance: [Grooming, dress, apparent age vs. stated]
• Behavior/Psychomotor: [Activity level, eye contact, engagement]
• Speech: [Rate, rhythm, volume, tone]
• Mood (reported): [Client's description]
• Affect (observed): [Range, congruence, reactivity]
• Thought Process: [Organization, coherence]
• Thought Content: [Including SI/HI screening results]
• Perception: [Hallucinations, illusions if assessed]
• Cognition: [Orientation, attention, memory as relevant]
• Insight: [Awareness of problems and need for treatment]
• Judgment: [Decision-making capacity]
• Reliability: [Assessment of historical reliability]
• Other participants: [Brief behavioral observations as relevant]

Safety/Risk Assessment

(If screening negative and no concerns identified, a brief statement suffices.)

• Suicide/Self-Harm: [Ideation, plan, intent, behaviors, access to means, past attempts, protective factors]
• Violence Risk: [Threats, intent, access to weapons, history, escalation risk, substance involvement]
• Abuse/Neglect Concerns: [Child, elder, dependent adult, or intimate partner concerns]
• Risk Level: [low / moderate / high] with rationale
• Mitigation Plan: [Safety plan status; lethal means counseling; emergency resources provided; mandated report if applicable; follow-up interval]

Standardized Measures

[Measure name, date administered, score, severity band, clinical interpretation, and linkage to treatment goals] (If indicated but not administered, note reason.)

Diagnostic Impression

Primary diagnosis: [ICD-10/DSM code and name with specifiers]

Secondary diagnoses/comorbidities: [List as applicable]

Relational problem focus: [e.g., Relationship Distress with Spouse or Intimate Partner / Parent-Child Relational Problem / other]

Psychosocial/contextual factors: [Z codes as applicable]

Differential diagnoses/rule-outs: [Include when clinically relevant]

Diagnostic rationale: [2-4 sentences linking symptoms, impairment, and duration to the impression] (Use "provisional" when certainty is limited. If evaluation incomplete, state "diagnostic impression deferred" with plan.)

Case Formulation

[Integrative paragraph: predisposing, precipitating, and perpetuating factors with protective factors; systemic interaction cycle maintaining distress; cultural/contextual influences on symptom expression]

Treatment Targets:

• [Target 1]
• [Target 2]
• [Target 3]

Treatment Plan

Target Problems: (List safety concerns first, then severe impairment, then relational/quality-of-life goals.)

• [Problem 1]
• [Problem 2]
• [Problem 3]

Goals: (For each problem, state measurable goal with observable change, measurement method, timeframe, and who goal applies to.)

• [Problem 1 Goal: Specific measurable outcome, measurement method, timeframe, applies to whom]
• [Problem 2 Goal: Specific measurable outcome, measurement method, timeframe, applies to whom]

Planned Interventions: [Psychoeducation topics; skills training; systemic interventions; trauma-informed approaches; parenting interventions as applicable]

Treatment Structure: [Type of therapy; frequency; expected duration; who attends which sessions; coordination of care needs]

Measurement Plan: [Scales to repeat and interval]

Client Collaboration: [Plan reviewed with client(s) and agreement obtained] (Note any disagreements and resolution approach.)

Prognosis & Recommendations

Prognosis: [good / fair / guarded] with [1-2 supporting reasons]

Referrals/Resources: [Psychiatry / group therapy / SUD treatment / DV resources / parenting supports / community resources as indicated]

Higher level of care: [Recommended / not indicated] (If recommended and declined, document discussion and safety steps.)

Next Steps

• Next appointment: [Date/time]
• Between-session tasks: [1-3 tasks for client/couple/family]
• ROIs to complete: [List]
• Collateral to obtain: [School, medical, prior therapy records, legal documents]
• Risk mitigation follow-up: [Safety plan check-in, means safety, reporting confirmation as applicable]