Presenting Problem
What the presenting problem is in a mental health intake, how it differs from the chief complaint and the diagnosis, what to include, and a fictional example.
Quick Answer
The presenting problem is the main difficulty that brings a person to treatment, described in enough detail to plan care: what is happening, when it started, how often and how severe it is, what makes it better or worse, how it affects daily life, and why the person is seeking help now. It is broader than the chief complaint, which is the person’s concern in their own words (often a short quote), and it is not the same as a diagnosis, which is the clinician’s conclusion after assessment.
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Definition
The presenting problem is the core of an intake or initial assessment. It turns the person’s reason for coming into a clinical description: the symptoms or difficulties, their onset and course, their frequency and severity, what triggers or eases them, how they affect work, relationships and self-care, and what the person has already tried. Many intake templates also ask “why now?”, because the event that prompted the first call often shapes what the person hopes to get from treatment.
A well-written presenting problem stays close to what the person and any collateral sources reported, and it separates their account from your observations. It sets the baseline you will measure progress against and supports the diagnosis, the treatment plan and, where it applies, medical necessity.
The presenting problem can change. Many people start with the concern that feels safest to name and raise others later. Update the assessment when a new main concern emerges.
Presenting problem vs chief complaint and diagnosis
These terms are often used loosely. In most mental health records they mean different things.
| Term | What it is | Whose words | Example wording |
|---|---|---|---|
| Chief complaint | The main concern in a sentence, ideally a direct quote | The client’s | “I can’t switch my brain off at night.” |
| Presenting problem | A clinical description of the main difficulty: onset, course, frequency, severity, triggers, impact and why now | The clinician’s summary of what the client and others reported | “Three months of difficulty falling asleep (4 to 5 hours a night), daily worry about money and irritability since being laid off; job applications down from about 10 to 2 a week; partner urged her to seek help.” |
| Reason for referral | Why another person or service sent the client | The referrer’s | “Referred by primary care for anxiety and sleep problems after a normal physical exam.” |
| Diagnosis | The clinician’s conclusion after assessment against diagnostic criteria, with an ICD-10-CM code for US documentation and billing; DSM-5-TR supplies diagnostic criteria and lists corresponding ICD-10-CM codes | The clinician’s | Recorded in the Assessment section once criteria have been reviewed. |
What to include in a presenting problem
A quick checklist for the presenting problem section of an intake:
- What: the main symptoms or difficulties, in the client’s words where possible
- When and how: onset, course (getting better, worse or staying the same) and any past episodes
- How often and how severe: frequency, duration and any screening scores
- Triggers and relief: what makes it worse or better, including substance use
- Impact: effects on work or school, relationships, sleep and self-care (see functional impairment)
- What has been tried: past treatment, medication, coping strategies
- Why now: what prompted the person to seek help at this point, and their goals
- Safety: the results of risk screening, documented separately
Weak documentation: “Client presents with anxiety.”
Stronger documentation: “Client reports 3 months of difficulty falling asleep (4 to 5 hours a night), daily worry about money and irritability since being laid off in July. Job applications have dropped from about 10 to 2 a week and she has stopped seeing friends. Sought help now because her partner was worried.”
Presenting problem in an initial session note
A short fictional example from a first session, written in SOAP format:
Subjective: Fictional 38-year-old client, initial session, self-referred. Chief complaint: “I can’t switch my brain off at night.” Presenting problem: since being laid off from her job in July (about 3 months), she takes 1 to 2 hours to fall asleep and sleeps 4 to 5 hours a night; worries daily about money and finding work; feels irritable with her partner and children. Job applications have dropped from about 10 to 2 a week and she has stopped meeting friends. Drinks 1 to 2 glasses of wine most nights “to sleep,” up from occasionally before July. No previous mental health treatment. Sought help now because her partner said she “isn’t herself.” Goals: sleep better and get back to job hunting.
Objective: Alert and oriented, appropriately dressed. Speech normal. Mood “wound up”; affect anxious, congruent. Thought process linear and goal-directed. Thought content: worries about money and work; denied suicidal and homicidal thoughts, intent or plan. PHQ-9 = 11; GAD-7 = 13; AUDIT-C = 4.
Assessment: Presenting problem of sleep difficulty, worry, irritability and reduced job seeking and social contact over 3 months following job loss, with increased evening alcohol use. Symptoms will be assessed further against DSM-5-TR criteria, including adjustment, anxiety and depressive disorders, insomnia and alcohol use, before a diagnosis is recorded.
Plan: Weekly sessions; next session to complete the biopsychosocial assessment and agree on treatment goals. Client agreed to keep a one-week sleep diary and to discuss her sleep and alcohol use with her primary care provider. Client knows to call or text 988 if thoughts of suicide arise, or to call 911 in an emergency.
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Tips for documenting the presenting problem
Quote the client once: Put the chief complaint in their own words, then describe the problem clinically.
Use numbers: Hours of sleep, days missed, panic attacks a week and screening scores make a baseline you can measure progress against.
Ask why now: The trigger for seeking help often explains the client’s goals and urgency.
Separate report from observation: What the client or family said goes in Subjective; what you observed goes in Objective.
Hold off on the diagnosis: Describe the problem first. Record a diagnosis once you have assessed the criteria.
Update it: If a different main concern emerges later, update the assessment and treatment plan.
Common mistakes to avoid
- A diagnosis instead of a description: “presents with GAD” says nothing about onset, severity or impact
- No timeline: onset and course are needed to judge severity and diagnosis
- No functional impact: how the problem affects daily life is central to planning care and medical necessity
- Mixing in your interpretation: keep the client’s account separate from your formulation
- Leaving out safety screening: document risk screening results even when they are negative
Frequently asked questions
What is a presenting problem in mental health?
The presenting problem is the main difficulty that brings a person to treatment, described clinically: what is happening, when it started, how often and how severe it is, what makes it better or worse, how it affects daily life and why the person is seeking help now.
What is the difference between the presenting problem and the chief complaint?
The chief complaint is the main concern in the client’s own words, often a short quote such as “I can’t switch my brain off at night.” The presenting problem is the clinician’s fuller description of that concern, including onset, frequency, severity, triggers and impact on daily life.
What should be included in a presenting problem?
Include the main symptoms or difficulties, onset and course, frequency and severity (with any screening scores), triggers and what helps, impact on work, relationships and self-care, past treatment, why the person is seeking help now and their goals. Record safety screening results as well.
Is the presenting problem the same as the diagnosis?
No. The presenting problem describes what the client and others report. The diagnosis is the clinician’s conclusion after assessing the criteria, and it is recorded in the Assessment section. The presenting problem is the evidence the diagnosis is built on.
How do you write a presenting problem example?
Start with the chief complaint in the client’s words, then describe the problem with specifics. For example: “Three months of difficulty falling asleep (4 to 5 hours a night), daily worry about money and irritability since being laid off; job applications down from about 10 to 2 a week; sought help because her partner was worried.”
Related guides: chief complaint · biopsychosocial assessment · functional impairment · intake assessment template · biopsychosocial assessment template.
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Further Reading
- DSM-5-TR — The American Psychiatric Association’s diagnostic manual. The diagnostic criteria the presenting problem is later assessed against; the manual does not prescribe how to write an intake note.
- NIMH (National Institute of Mental Health) — Plain-language information on mental health conditions, their symptoms and current research.
- Intake assessment template — Where the presenting problem fits in a full intake, with the other sections and a fictional completed example.