What a therapy intake assessment is
The intake assessment is the first clinical note in a client's record, and the one every later note builds on. It records what the client told you, what you observed, and the reasoning that led to a working diagnosis and a plan. The treatment plan, the first progress notes and any insurance authorization usually draw on it.
People often mix it up with the paperwork that comes before it. The forms a client completes before the first visit collect facts in the client's own words. The intake assessment is your clinical judgment about those facts, after you've met the client.
Intake assessment or another first-session document?
| | |
|---|
| The client, before the first visit | History, symptoms and goals in the client's own words |
| | Contact details, insurance, consents, emergency contact |
Therapy intake assessment (this page) | The clinician, after the first session | Clinical findings, risk, working diagnosis and initial plan |
Biopsychosocial assessment | The clinician, often across more than one session | A fuller history, required by many agencies and programs |
| A psychiatrist or psychiatric nurse practitioner | Diagnosis plus medication assessment |
What a therapy intake note should cover
- Identifying information and referral source.
- Presenting problem, in the client's words, with onset and duration.
- History of the present problem and what the client has already tried.
- Past mental health treatment, hospitalizations and medications.
- Substance use, with a screening score if you use one.
- Medical history and current medications.
- Family, social, work and legal history, kept to what bears on the problem.
- Risk assessment: suicide, self-harm, harm to others, and safety at home.
- Mental status exam.
- Strengths and supports.
- Working diagnosis with ICD-10 codes, and what still needs ruling out.
- Initial plan: frequency, approach, referrals, and when the treatment plan will be written.
That list is long, and a 60‑minute first session rarely covers all of it. Document what you didn't get to and when you'll come back to it. An honest "not yet assessed" is better than a blank section a reader might take as "none."
Therapy intake assessment example
Mark is a fictional client. Every detail below is invented for illustration.
Identifying information and referral: Mark, 46, high school teacher, referred by his primary care physician for low mood. Self‑pay for the first session; insurance verification pending.
Presenting problem: "Since my wife moved out in May, I come home and just sit there." Low mood most days for about four months, poor concentration at work, and drinking four or five beers most evenings, up from one or two.
History: One course of counseling in his twenties after his father's death, which he found helpful. No hospitalizations. No psychiatric medication. Takes lisinopril for blood pressure. Two children, 12 and 15, who stay with him every other weekend.
Screening: PHQ‑9: 13. AUDIT‑C: 7, a positive screen. C‑SSRS screener: passive wish to be dead in June, none in the past month, no plan, intent or behavior ever.
Mental status: Well groomed, cooperative, good eye contact. Speech normal. Mood "flat"; affect constricted, tearful when discussing the children. Thought process logical, no psychotic symptoms. Oriented. Insight and judgment fair.
Risk: Low current risk. Protective factors: his children, his job, no firearms in the home (confirmed), willingness to engage. Alcohol use raises risk and is a treatment focus.
Strengths: Stable job, close friendship with a colleague, previous good response to therapy.
Working diagnosis: Adjustment disorder with depressed mood (F43.21). Disruption of family by separation and divorce (Z63.5). Alcohol use needs a full assessment before a substance use diagnosis is made.
Plan: Weekly individual sessions, CBT focus. Full alcohol use assessment and treatment plan at session 2. Release of information signed for his primary care physician; send a summary after session 2. Gave crisis line information. Repeat PHQ‑9 at session 4.
Blank therapy intake assessment template
Copy the headings below. The prompts in each line are the questions to answer; delete them as you write.
- Identifying information: name or ID, age, pronouns, occupation, referral source, payer.
- Presenting problem: the client's words, onset, duration, what made them seek help now.
- History of the present problem: course, triggers, previous attempts to cope.
- Mental health history: prior treatment, hospitalizations, medications and response.
- Substance use: substances, amount, frequency, screening tool and score.
- Medical history: conditions, medications, primary care provider.
- Family and social history: relationships, living situation, work or school, legal issues, culture and identity where relevant.
- Risk assessment: suicidal and homicidal ideation, self-harm, access to means, protective factors, overall risk level.
- Mental status exam: appearance, behavior, speech, mood and affect, thought process and content, perception, cognition, insight and judgment.
- Strengths and supports:
- Working diagnosis: diagnoses with ICD-10 codes, and what remains to be assessed.
- Initial plan: session frequency, approach, referrals, releases signed, date the treatment plan will be completed.
- Clinician signature, credentials, date:
Billing the intake: 90791 and 90792
Most outpatient intakes are billed with 90791, the psychiatric diagnostic evaluation without medical services. When a psychiatrist or other prescriber evaluates the client and also provides medical services, such as a medication assessment, the code is 90792. Payers set their own limits on how often these can be billed, so check before scheduling a second evaluation session.
CPT is a registered trademark of the American Medical Association. CPT codes copyright 2026 American Medical Association. All rights reserved.
HIPAA at intake
The intake is when the Notice of Privacy Practices is due. A provider with a direct treatment relationship has to give it no later than the first service delivery, and must make a good faith effort to get a written acknowledgment that the client received it. If the client won't sign, document your attempt (45 CFR 164.520). Our notice of privacy practices template can be handed out with the intake forms.
Common intake assessment mistakes
- Copying the client's questionnaire answers into the note without your own findings.
- A risk section that says only "denies SI." Record what you asked, over what time frame, access to means, and your overall judgment.
- Giving a firm diagnosis the first session can't support. A working diagnosis with a note on what still needs assessing is more accurate.
- No mental status exam, which leaves nothing to compare later sessions against.
- Ending without a date for the treatment plan.
Writing intake notes with Twofold
Twofold's Template menu includes Intake (Mental Health). Record the first session, press End, and the draft is organized under intake headings for you to review. The steps are the same as in our University guide on writing a SOAP note from a live session, with the Intake template chosen instead. See AI therapy notes for the other note types.
Mental health intake assessment template, counseling intake form template, intake questionnaire template, biopsychosocial assessment template, mental status exam checklist and treatment plan template.
Reviewed and updated October 2026.
