Therapy Intake Note Template: First Session Documentation Guide

What Is an Intake Note?

An intake note — also called an initial assessment, intake evaluation, or diagnostic assessment — is the comprehensive clinical document created after the first therapy session with a new client. It is the foundation of the entire clinical record and establishes the baseline against which all future progress will be measured.

Unlike a progress note, which documents a single session in an ongoing course of treatment, the intake note captures a broad picture of the client's presenting problems, history, current functioning, risk factors, mental status, and preliminary diagnostic impressions. It answers the fundamental clinical question: who is this person, what brought them to treatment, and what is the initial plan for addressing their needs?

The intake note is typically the most detailed document in a client's chart. It is used by the clinician to formulate the treatment plan, by insurance companies to authorize treatment, by other providers for coordination of care, and — if needed — by legal and regulatory bodies to evaluate the quality and appropriateness of care. A thorough, well-organized intake note protects both the client and the clinician from the first day of treatment.

When You Need It

• After the first session with every new client, without exception
• When a client returns to treatment after a significant gap (typically six months or more) and a new episode of care is opened
• When a client transfers from another clinician within your practice and you are conducting a new evaluation
• When a client's clinical picture has changed substantially enough to warrant a comprehensive reassessment
• When insurance or agency requirements mandate an updated initial assessment for reauthorization

Key Components of an Intake Note

Identifying Information and Referral Source

Establish who the client is and how they came to treatment.

Include:

• Client demographics: age, gender identity, pronouns (if relevant to clinical context), relationship status, living situation
• Referral source: self-referred, physician referral, court-ordered, school referral, etc.
• Insurance or payment method
• Date of evaluation and clinician name/credentials

Presenting Problem and History of Present Illness

Document why the client is seeking treatment now, in their own words and in clinical terms.

Include:

• Client's stated reason for seeking therapy, using direct quotes when possible
• Onset, duration, frequency, and severity of current symptoms
• Precipitating events or triggers that prompted seeking treatment at this time
• Impact on daily functioning — work, relationships, self-care, sleep, appetite
• Any prior treatment for this issue and the outcome

Psychiatric and Treatment History

Document the client's mental health background.

Include:

• Previous diagnoses
• Previous therapy, counseling, or psychiatric treatment — when, with whom, what type, and outcome
• Previous psychiatric hospitalizations or emergency department visits
• Current and past psychotropic medications
• History of suicidal ideation, attempts, or self-harm

Medical History

Relevant medical information that may affect mental health treatment.

Include:

• Current medical conditions and medications
• History of head injury, neurological conditions, or chronic pain
• Sleep and appetite patterns
• Current or recent pregnancy (if applicable)
• Primary care provider and date of last physical exam

Substance Use History

Screen for substance use regardless of the presenting problem.

Include:

• Current and past use of alcohol, cannabis, nicotine, and other substances
• Frequency, quantity, and pattern of use
• History of substance use treatment
• Current sobriety status and length if applicable

Family and Social History

Document the client's interpersonal and environmental context.

Include:

• Family of origin: structure, significant relationships, family mental health history
• Current relationships: partner, children, support system
• Employment or educational status
• Housing stability and financial stressors
• Cultural, spiritual, or religious factors relevant to treatment
• Legal involvement if applicable
• History of trauma or abuse (screen; detailed exploration may occur in later sessions)

Mental Status Examination

Document your clinical observations of the client during the evaluation.

Include:

• Appearance and grooming
• Behavior and psychomotor activity
• Speech (rate, volume, tone)
• Mood (client-reported) and affect (clinician-observed)
• Thought process (linear, tangential, circumstantial, etc.)
• Thought content (suicidal ideation, homicidal ideation, delusions, obsessions)
• Perceptual disturbances (hallucinations)
• Cognition (orientation, attention, memory — if formally or informally assessed)
• Insight and judgment

Risk Assessment

Evaluate and document the client's current safety status.

Include:

• Suicidal ideation: current and historical, passive versus active, plan, intent, means
• Homicidal ideation or intent to harm others
• Self-harm behaviors: current and historical
• Risk factors (isolation, substance use, recent loss, access to lethal means, impulsivity)
• Protective factors (social support, reasons for living, engagement in treatment, future orientation)
• Current risk level determination and rationale
• Safety plan if indicated

Diagnostic Impression

Provide your preliminary clinical diagnosis based on the evaluation.

Include:

• DSM-5-TR diagnosis code and description
• Provisional qualifiers or rule-out diagnoses if applicable
• Clinical rationale connecting symptoms to the diagnosis
• Relevant specifiers (severity, episode type, etc.)

Initial Treatment Plan

Outline the preliminary plan for treatment.

Include:

• Recommended treatment modality and frequency (e.g., weekly individual CBT)
• Preliminary treatment goals
• Referrals made (psychiatric evaluation, medical clearance, group therapy, etc.)
• Coordination of care planned
• Estimated treatment duration if assessable
• Date of next session

Filled-In Intake Note Example

How to Write an Intake Note Step by Step

Step 1: Gather information before and during the session. Have the client complete an intake questionnaire or intake paperwork before the session that covers demographics, presenting problem, psychiatric history, medical history, substance use, and family history. This allows you to use the face-to-face time for clinical interview, clarification, and rapport building rather than fact-gathering.

Step 2: Write the presenting problem and history of present illness first. This is the clinical heart of the intake note. Document what brought the client to treatment using both their own words and your clinical framing. Include onset, duration, severity, precipitating factors, and functional impact. This section should make it clear to any reader why this person needs treatment now.

Step 3: Document the history sections. Working from your intake questionnaire and clinical interview, complete the psychiatric history, medical history, substance use, and family and social history sections. These sections provide the context that informs your diagnostic impression and treatment plan. Be thorough but relevant — document what matters clinically, not every detail of the client's biography.

Step 4: Write the mental status examination. Document your observations of the client's appearance, behavior, speech, mood, affect, thought process, thought content, perceptions, cognition, insight, and judgment. This is your professional snapshot of how the client presented during the evaluation, and it serves as the baseline against which future mental status observations will be compared.

Step 5: Complete the risk assessment. Document suicidal ideation (passive or active, plan, intent, means), homicidal ideation, self-harm history, specific risk factors, specific protective factors, your overall risk level determination, and any safety interventions implemented. This section must be present in every intake note without exception.

Step 6: Formulate the diagnostic impression. Based on the information gathered, provide your clinical diagnosis using DSM-5-TR criteria. Include any provisional or rule-out diagnoses. Briefly note the clinical reasoning that supports your diagnostic impression — this demonstrates that the diagnosis is evidence-based, not arbitrary.

Step 7: Write the initial treatment plan. Document your recommended treatment modality, frequency, therapeutic approach, preliminary goals, planned referrals, and next appointment. This section bridges the evaluation into active treatment.

Step 8: Review the complete note for accuracy and compliance. Verify that all sections are complete, the risk assessment is documented, the diagnosis is supported by the documented symptoms, and the treatment plan logically follows from the clinical presentation. Ensure no sensitive details are included that should be reserved for psychotherapy notes. Sign, date, and finalize.

Common Mistakes

1. Skipping the substance use screening. Every intake must include a substance use screen, regardless of the presenting problem. Substance use is comorbid with nearly every mental health condition and can dramatically alter treatment planning, medication decisions, and risk assessment. Even a brief, negative screen should be documented — "Client denies current and past use of alcohol and all substances" — to demonstrate that you asked.

2. Documenting a diagnosis without supporting evidence in the note. If you diagnose Major Depressive Disorder, the note must contain enough documented symptoms to meet DSM-5-TR criteria. An auditor or reviewer reading your intake should be able to trace a clear line from the symptoms documented in the presenting problem and mental status exam to the diagnosis assigned. Diagnoses that appear unsupported create billing and legal liability.

3. Conducting an incomplete risk assessment. An intake risk assessment must be more than "client denied SI." Document the specific questions you asked, the client's responses, identified risk factors and protective factors, your risk level determination, and any safety interventions. The intake sets the baseline for risk monitoring throughout treatment — if it is vague, every subsequent assessment lacks context.

4. Omitting the client's own words. The presenting problem section should include at least one or two direct quotes from the client that capture their reason for seeking treatment. Phrases like "I can't keep living like this" or "My wife said I need to talk to someone" provide important clinical context that paraphrasing alone cannot convey. Direct quotes also demonstrate that you listened to and documented the client's perspective.

5. Writing a treatment plan that does not match the diagnosis. If you diagnose PTSD, the treatment plan should reference evidence-based interventions for PTSD (CPT, PE, EMDR). If you diagnose Generalized Anxiety Disorder, the plan should include approaches with demonstrated efficacy for GAD. A mismatch between diagnosis and treatment plan suggests the clinician is applying a one-size-fits-all approach rather than individualized, evidence-based care. Auditors and clinical reviewers specifically look for this alignment.