I've walked into a therapist's office more times than I can count, the first time at eight, and every time my body treated it like a job interview I hadn't prepared for. Sweaty hands. An opening line I'd rehearsed in the car. Then I'd sit down and do what I do in every room, which is perform. Funny, a bit too articulate, very likeable. Fifty years of masking before anyone told me I had ASD, so of course I masked for the one person I was paying to see the real me.
So here's the plain answer, before the stories. A first session is mostly an intake. The therapist asks why you came and why now. They ask about your history, your health, your sleep, what you drink and what you use, your family, and if you're safe. They explain confidentiality and where it stops, plus fees and how often you'd meet. Nothing gets fixed in that hour. It's two people finding out if they can work together.
That's it. It's less dramatic than the version in your head.
What do they ask in the first session?
A lot. Some of it feels like a form read out loud, because it partly is.
Expect questions about what's going on now, what you've already tried, past diagnoses, medication, physical health, work, relationships. Expect substance use questions. Expect a direct question about suicide. They're not being nosy and they're not judging you. They ask everyone, and they need the answer to know how to help.
I have an attempt in my past, in 1998. For years that question made my throat close up. Now I just say it. The room doesn't explode. The therapist writes something down, asks how I'm doing today, and we move on. If you're carrying something like that, you can say it in one sentence and stop there. You don't owe anyone the whole story on day one.
They'll also ask what you want. That one stumped me. "To stop being like this" was the only thing I could come up with, which was more of a scream than a goal. A decent therapist takes the scream and helps you turn it into something you can work on.
Confidentiality, paperwork and the boring bits
There's usually a consent form. Read it. It covers what they keep in their notes, who can see them, and the limits of confidentiality. Those limits matter: if they believe you or someone else is in serious danger, they may have to act. Most therapists explain this out loud too. Ask if they don't.
Then money. In Québec, public mental-health services through a CLSC or your family doctor are free, but the waits can be long. Private psychologists set their own rates. The Ordre des psychologues du Québec says plainly that there's no fee schedule in private practice, it's a free market. Ask about the price, the cancellation policy and whether they give receipts for your insurance before you're halfway through the hour. I wrote a whole post on what therapy costs in Québec if you want the details.
Check that the person is actually licensed. The OPQ has a directory on its where to find a psychologist page. In the US the APA Psychologist Locator does a similar job.
How do you know if the therapist is right for you?
You won't know for sure after one hour. You'll have a hint.
The US National Institute of Mental Health says it simply: rapport and trust are essential, and it's fine to have a short preliminary conversation first to see if you're comfortable. I didn't know that for most of my life. I thought you took who you got and shut up about it.
Things I pay attention to now:
- Did they let me finish my sentences, or did they jump to a technique in the first ten minutes?
- When I said "autistic", did they get curious, or did they get that polite blank look?
- Did I leave feeling a bit raw but respected? Raw is normal. Small and stupid is not.
If the answer is bad, you can leave and find someone else. Nobody gets hurt. I used to think switching therapists was a failure on my part. It's more like returning shoes that don't fit.
What I'd tell an autistic adult before the first appointment
This part is for people like me, the late-diagnosed and the "I'm fine" crowd.
Write it down. On the day, my brain goes blank or goes into show mode, and either way the important stuff stays in my pocket. A few lines on my phone (what's happening, what scares me, what I want) saves the session. You can even hand it over and say "read this, it's easier."
Ask about the room if it matters to you. Lights, noise, sitting across a desk versus side by side, video versus in person. A therapist who knows autism won't find that strange. If you're looking for one, I put together what I learned about finding an autism-aware therapist in Québec.
And watch the performance. I once spent a full first session being charming and didn't say one true thing. Walked out, felt great for an hour, then felt like shit, because I'd paid someone to watch me act. The second time I said "I'm going to be honest, I'm good at faking this" and it changed everything. The therapist laughed. Then we got to work.
What happens after the first session?
Usually you book a second one. Some therapists will give you a rough plan: what kind of therapy they're thinking about (CBT, DBT, ACT, something else; I explain those in CBT, DBT, ACT in plain words), how often, and for roughly how long. Some just say "let's keep talking for a few weeks and see." Both are normal.
You might feel worse for a day or two. Stirring the mud does that. If it keeps getting worse over weeks, say so in session. NIMH's advice is the same: if you're not getting better after a reasonable stretch, tell your therapist.