Diagnostic Assessment Sample

Clients:

  • Identified Client (IC): Jae (they/them), 29 — Hmong American (3rd gen.), nonbinary; works remotely as an online adult performer; uses an AI companion app nightly “to practice talking about feelings/feel less alone”; uses dating apps with desirability rankings and noted fewer matches after listing nonbinary.

  • Partner: Maya (she/her), 31 — Han Chinese; in U.S. on an H-1B; discovered Jae’s AI-companion use; reports feeling betrayed and hurt by perceived “algorithmic preferences.”

  • Intake source: Completed by intake team - Chapi M.

I. Presenting Concerns & Initial Goals

  • Primary concerns: Erosion of trust and intimacy after discovery of AI-companion chats; disagreements about tech boundaries; shame (Jae) and betrayal/jealousy (Maya); conflict around dating-app activity and profile settings.

  • Couple goals (stated): Obtain guidance without “breaking up with tech,” reduce conflict, rebuild trust, and improve direct emotion sharing.

II. Relevant History

  • Relationship: Duration, cohabitation status, prior agreements about exclusivity/tech not yet documented. History of similar ruptures unknown.

  • Psychiatric hx: No formal diagnoses or treatment reported yet. Substances, sleep, medical conditions, and medication use—TBD.

  • Work/role demands: Jae’s remote schedule/content creation may affect availability and boundaries; Maya’s employment is time-bound to visa and may heighten stress.

  • Technology use: Frequency, content, and privacy settings for AI/dating apps to be clarified; obtain examples only with informed consent.

III. Current Functioning

  • Communication: Escalates around AI/dating-app topics; cycles of protest/defensiveness then distance.

  • Intimacy/attachment needs: Jae reports feeling calmer after AI chats and ashamed when confronted; Maya reports feeling devalued and preoccupied with comparisons.

  • Daily impact: Sleep/attention may be affected by late-night app use and arguments (to be measured).

IV. Mental Status Examination

  • Jae: On time; cooperative; appearance appropriate; mood “ashamed/ambivalent”; affect congruent; thought process linear; no SI/HI/psychosis endorsed; insight good regarding emotion-practice rationale; judgment intact for daily decisions.

  • Maya: Slightly late by 5 minutes; cooperative; appearance appropriate; mood “hurt/angry”; affect constricted to tearful; thought process linear; no SI/HI/psychosis endorsed; insight fair; judgment intact.

V Risk & Safety

  • Suicide/SIB/violence: Denied; complete C-SSRS for both.

  • IPV/coercion: Screen privately and together; no reports at intake.

  • Occupational privacy/legal: Review doxxing/harassment risks related to Jae’s work and visa-related stressors for Maya; create a basic safety and digital-privacy plan if needed.

  • Acute risk today: Not indicated; provide crisis resources.

VI. Measurement-Based Care (baseline + monitoring)

  • Relationship: Couples Satisfaction Index (CSI-16); Trust Scale (Rempel/R); Relationship Assessment Scale (RAS).

  • Individual symptoms: PHQ-9, GAD-7 (both); Perceived Stress Scale (PSS-10).

  • Technology impact: Problematic Usage of the Internet Questionnaire (short form) or IAT-Short; Technoference/Phubbing brief checklist; sleep diary (7–14 days).

  • Process: Session Rating Scale (SRS) each session.

VII. Differential Diagnosis (working; data pending)

Couple/relationship problem (primary billing focus):

  • Z63.0 Relationship distress with spouse or intimate partner — working diagnosis.

Individual rule-outs (no diagnoses assigned at intake):

  • Adjustment Disorder with Mixed Anxiety and Depressed Mood (F43.23) — if symptoms temporally linked to discovery/ongoing conflict.

  • Other Specified Anxiety Disorder (F41.8) — if worry/physiological arousal present outside conflicts.

  • Insomnia Disorder (F51.01) — if sleep disturbance persists ≥3 months.

  • Unspecified depressive disorder (F32.A) — if low mood/anhedonia meet criteria.
    (No evidence of compulsive sexual behavior disorder collected; not a DSM-5-TR diagnosis; screen only if clinically indicated.)

VIII. Psychosocial/Context Codes

  • Z56.3 Stressful work schedule (Jae).

  • Z60.8 Other specified problems related to social environment (ongoing conflict tied to technology use).

  • Z63.5 Disruption of family by separation or divorce (use only if separation occurs).

  • Z60.2 Problems related to living alone (if applicable).

  • Z75.8 Other problems related to health-care system (if coordination around privacy/tech consents required).

IX. Medical Necessity

Couple therapy is indicated to reduce clinically significant relational distress causing sleep disturbance, concentration problems, and recurrent conflicts that impair daily functioning and relationship stability. Caregiver/partner participation is essential to modify interaction patterns, establish agreements, and reduce maintaining factors (avoidance, secrecy, late-night tech use).

X. Treatment Plan (12–16 weeks; adjust by response)

Modality & cadence: Weekly 60-minute integrative couple therapy (IBCT/EFT-informed skills + behavioral agreements); optional brief individual check-ins only for safety.

Interventions:

  1. Clarify structure/agreements: Define exclusivity, acceptable tech uses (AI companion, dating apps), disclosure expectations, and privacy boundaries; write a 30-day Tech Agreement with review dates.

  2. De-escalation & communication: Teach time-outs, speaker–listener, and emotion labeling; increase direct bids for connection; schedule two 10-minute daily check-ins.

  3. Trust repair tasks: Transparency protocols (e.g., when and how AI/dating apps are used), apology/impact statements, and planned reassurance versus interrogation.

  4. Emotion skills (Jae): Replace AI-only processing with in-vivo partner sharing (graduated practice: 1–2 feelings/night); track shame triggers; brief cognitive coping.

  5. Emotion skills (Maya): Tolerate uncertainty, reduce monitoring behaviors that escalate conflict, identify specific reassurance needs, and practice self-soothing.

  6. Behavioral experiments: Adjust app timing (e.g., no use within 90 minutes of bedtime), test alternative connection rituals, and compare mood/sleep outcomes.

  7. Sleep hygiene & stress: Regular wake time, screen cut-off, wind-down routine; brief relaxation training.

  8. Privacy/ethics: Document consent about reviewing any digital content; no compelled sharing; therapist does not access devices.

  9. Monitor & adapt: Reassess CSI-16, PHQ-9/GAD-7 at sessions 4, 8, 12; step up/down care as indicated.

Measurable outcomes:

  • CSI-16 ↑ by ≥8 points from baseline by week 10.

  • Nightly conflict episodes ↓ to ≤1/week by week 6.

  • Sleep onset <30 minutes on ≥5 nights/week by week 8.

  • PHQ-9/GAD-7 decrease into nonclinical/mild ranges if elevated.

XI. Prognosis

Fair to good with adherence to the Tech Agreement, consistent emotion-sharing practice, and reduction of late-night app use that fuels conflict.

XII. Administrative Follow-ups

  1. Obtain informed consent for couple therapy (including limits of confidentiality and handling of digital materials).

  2. Complete baseline measures and ROIs as needed (no device access without explicit consent).

  3. Schedule weekly sessions for 4–6 weeks, then review cadence.

XIII. Working Diagnoses

  • Z63.0 Relationship distress with spouse or intimate partner — primary

  • No individual mental disorder diagnosis assigned at intake.