Templates
Therapy Intake Note Template
The intake session sets the foundation for the entire therapeutic relationship. This template provides a comprehensive framework for documenting initial assessments, client history, presenting concerns, and preliminary treatment planning.
What to Document During Intake
The intake note should capture a comprehensive picture of the client including demographics, presenting concerns, mental health history, medical history, family history, social history, substance use assessment, risk assessment, and preliminary diagnostic impressions.
Setting Treatment Goals
Use the intake assessment to establish specific, measurable treatment goals collaboratively with the client. Document both the client's stated goals and your clinical recommendations. These goals will guide treatment planning and progress evaluation throughout therapy.
Legal and Ethical Documentation
Record that informed consent was obtained and reviewed. Document any limits to confidentiality that were discussed, including mandatory reporting obligations. Note the client's understanding and agreement to treatment terms.
Date: ___________ Referral Source: ___________ Client Information: [Demographics, emergency contact, insurance] Presenting Concerns: [Primary reason for seeking therapy, onset, duration, severity] Mental Health History: [Previous therapy, hospitalizations, medications, diagnoses] Medical History: [Relevant medical conditions, current medications, primary care provider] Family History: [Mental health in family, family structure, significant relationships] Social History: [Education, employment, living situation, support system] Substance Use Assessment: [Current and past use, substances, frequency, last use] Risk Assessment: Suicidal ideation: [Denied / Details] Homicidal ideation: [Denied / Details] Self-harm history: [Denied / Details] Trauma history: [Denied / Details] Mental Status Examination: [Appearance, behavior, speech, mood, affect, thought process, cognition, insight] Diagnostic Impressions: [Preliminary diagnoses, rule-outs, differential considerations] Treatment Goals: 1. ___________ 2. ___________ 3. ___________ Treatment Plan: Modality: ___________ Frequency: ___________ Estimated duration: ___________ Informed Consent: [Obtained / Reviewed / Signed — date] Clinician: ___________ Credentials: ___________
Frequently Asked Questions
What should a therapy intake note include?
A therapy intake note should include presenting concerns, mental health and medical history, family and social history, substance use assessment, risk assessment, mental status examination, diagnostic impressions, treatment goals, and documentation that informed consent was obtained.
How long should an intake assessment take?
An intake assessment typically takes 60 to 90 minutes. Some therapists spread the intake across two sessions to be thorough without overwhelming the client. The documentation should capture all relevant clinical information gathered.
Can AI assist with intake documentation?
AI tools can help organize intake assessment notes into structured documentation. LeafNote can generate organized clinical notes from raw session notes while scrubbing sensitive identifiers before processing.
Related Resources
Generate structured SOAP notes with LeafNote
LeafNote turns reviewed, scrubbed therapy session notes into structured SOAP drafts. Supported identifier patterns are replaced locally and presented for review before submission.
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