Therapy Intake Form and Intake Assessment Template
A therapy intake has two parts: the intake form the client fills in before the first session (contact details, history questions, consents) and the intake assessment you write after it (presenting problem, history, mental status, risk, impressions and plan). Below is a copy-ready outline for both, a fictional worked example, and what to check before you sign.
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General documentation guidance, not legal or billing advice. Consent, record-keeping and minor-consent rules vary by state, licence and payer; check yours. All examples are fictional.
Quick answer
- Intake form (client completes): contact and emergency contact, date of birth, insurance or self-pay, reason for seeking therapy, symptoms, past treatment, medications and prescriber, medical conditions, substance use, family and social background, goals.
- Intake paperwork (client signs): informed consent for treatment, Notice of Privacy Practices acknowledgment, fee and cancellation policy, telehealth consent if you see clients by video, release of information where required for the intended disclosure, and a Good Faith Estimate for uninsured or self-pay clients.
- Intake assessment (you write): 14 sections from presenting problem to plan, with mental status, risk and safety, and clinical impressions. Template below.
- Before you sign: the presenting problem, risk assessment, diagnosis (if any) and plan should line up, and anything not assessed should say so.
Part 1: client intake form template
Copy these fields into your form builder or EHR. Keep the form to what you will use: every extra question is more data you have to protect.
| Section | Fields |
|---|---|
| Client information | Name, preferred name and pronouns, date of birth, address, phone, email, preferred contact method and whether messages may be left |
| Emergency contact | Name, relationship, phone |
| Payment | Insurance carrier, member ID and policyholder, or self-pay; secondary insurance |
| Reason for seeking therapy | In the client's words: what brings them in now, how long it has been going on, what they hope will change |
| Current symptoms | Checklist (low mood, anxiety, sleep, appetite, concentration, irritability, panic, intrusive memories, substance use concerns, other) plus "anything else" |
| Screening measures | Optional: PHQ-9 and GAD-7, or the measures your practice uses, scored before the first session (see screening measures in progress notes) |
| Mental health history | Past therapy or psychiatric care, hospitalizations, past diagnoses, what helped and what did not |
| Medical | Primary care provider, current medical conditions, current medications and prescriber, allergies |
| Substance use | Alcohol, cannabis, nicotine, other substances: how often and how much |
| Family and social | Household, relationships, children, work or school, cultural or spiritual background the client wants you to know |
| Safety | Current or past thoughts of suicide or self-harm, with instructions on what to do in a crisis (988 in the US, or emergency services) |
| Goals | What the client wants to be different at the end of therapy |
A form answer about suicide or self-harm is a starting point, not a risk assessment. Explain when submitted forms are reviewed and that the form is not an emergency contact channel. When a concerning response is identified, assess and respond promptly under your clinical protocol; do not automatically wait for the first appointment. Document the questions asked, findings and actions. For immediate danger or a medical emergency, call 911; for suicide or mental health crisis support in the US, call or text 988.
Part 2: intake paperwork checklist
- Informed consent for treatment: what therapy involves, limits of confidentiality (for example risk of harm, abuse reporting, court orders), how to reach you, and the client's right to stop.
- Notice of Privacy Practices acknowledgment: HIPAA requires a covered provider to give the notice by the first service and make a good-faith effort to get written acknowledgment of receipt (45 CFR 164.520(c)(2)).
- Fee, cancellation and no-show policy.
- Good Faith Estimate for uninsured or self-pay clients, under the No Surprises Act rules (45 CFR 149.610).
- Telehealth consent if you will see the client by video or phone. Rules differ by state.
- Release of information (authorization) when required for the intended disclosure. HIPAA generally permits sharing ordinary clinical records with another provider for treatment without authorization; separately maintained psychotherapy notes and other specially protected records may require it. Check applicable federal and state rules, including school-related disclosures. When authorization is required, specify the information, authorized recipient(s) or permitted recipient class, purpose and expiration, and obtain the required signature.
- Minors: consent from a parent or guardian, or from the minor where your state allows it, and who can access the record.
Part 3: intake assessment template (14 sections)
Use this structure for the clinician's note after the first session. It matches the Intake / Biopsychosocial format in MentalNote. For a longer walkthrough of the biopsychosocial model, see the biopsychosocial assessment template.
| Section | What to document |
|---|---|
| 1. Identifying information | Age range, pronouns, living situation, referral source. Keep it to what the note needs. |
| 2. Reason for referral and presenting problem | Why the client is here now, in their words and yours. |
| 3. History of the presenting problem | Onset, duration, course, triggers, what has been tried, impact on work, school, relationships and self-care. |
| 4. Psychiatric and treatment history | Past diagnoses, therapy, hospitalizations, medication trials and response. |
| 5. Medical history and medications | Current conditions, current medications and prescriber, allergies, last primary care visit. |
| 6. Substance use | Each substance: frequency, amount, last use, consequences, past treatment. |
| 7. Family history | Mental health and substance use in the family, family relationships now. |
| 8. Social, developmental and cultural history | Upbringing, education, work, relationships, supports, culture, faith and identity factors the client raises, legal issues. |
| 9. Trauma history | What the client chose to share, at the level of detail they chose. Not assessed is an acceptable entry. |
| 10. Strengths and supports | Personal strengths, people, routines and resources the plan can use. |
| 11. Mental status observations | Appearance, behavior, speech, mood and affect, thought process and content, perception, cognition, insight and judgment. See the mental status exam template. |
| 12. Risk and safety | Suicidal and homicidal ideation, self-harm, history of attempts, access to means, protective factors, the risk formulation and any safety plan. Record only what you actually asked and heard. |
| 13. Clinical impressions | Your formulation and diagnosis if one is made, with the criteria the session supports. |
| 14. Recommendations and plan | Frequency and type of treatment, referrals, measures to repeat, what to cover next session, when the treatment plan will be completed. |
Fictional example: intake assessment (shortened)
Fictional example. Not a real client.
Identifying information: Adult in their 30s, she/her, lives with a partner, self-referred.
Presenting problem: Worry about work and health "most of the day" for about 8 months, trouble falling asleep, irritability. Client says: "I can't switch my brain off."
History of presenting problem: Started after a promotion with longer hours. Has tried exercise apps and cutting caffeine with little change. Missed two work deadlines last month.
Psychiatric and treatment history: Brief counseling in college for exam stress, found it helpful. No hospitalizations. No psychiatric medications.
Substance use: 1 to 2 glasses of wine on weekends. No other substances reported.
Trauma history: Not assessed this session.
Mental status observations: Casually dressed, cooperative, speech normal rate, mood "on edge", affect anxious, thought process linear, no perceptual disturbances reported.
Risk and safety: Asked about thoughts of suicide or self-harm: denies current or past. Asked about thoughts of harming others: denies. Crisis resources, including 988, reviewed.
Clinical impressions: Excessive worry more days than not for over 6 months with restlessness, irritability and sleep disturbance, causing impairment at work. Consistent with generalized anxiety disorder; the clinician confirms the diagnosis and code.
Recommendations and plan: Weekly CBT. GAD-7 at each session. Client to keep a worry log. Trauma history and family history to be covered at session 2; treatment plan at session 2.
The note shows what was asked in the risk section, marks trauma history as not assessed rather than leaving it blank, and ties the impression to the history. For the codes, see anxiety, PTSD and adjustment disorder ICD-10 codes. For billing the first session, see CPT 90791 vs 90792 intake documentation.
Before you sign the intake
- The presenting problem, impressions and plan tell one consistent story.
- The risk section records what you asked and what the client said, and the plan matches the risk you found.
- Any diagnosis is supported by the history and observations in the note.
- Topics you did not cover say "not assessed" and appear in the plan for next session.
- Obtain and document the treatment and telehealth consent required by applicable law, and any required authorization before disclosure. Separately, give the Notice of Privacy Practices and seek written acknowledgment of receipt; if acknowledgment cannot be obtained, document the good-faith effort and why it was not obtained.
- The intake is in the record before the next session, within your practice's documentation timeline.
How MentalNote fits
MentalNote drafts the intake assessment from the recorded first session (with your client's consent): choose Intake / Biopsychosocial and you get the 14 sections above, with anything the session did not cover marked "Not documented in session". It does not fill in your intake forms or consents. The app instructs the AI not to add a diagnosis or risk rating you did not state, but these instructions are not a guarantee. Review and correct every draft before it goes in the record. See the AI intake note generator and, at the end of treatment, the discharge summary template.
MentalNote is HIPAA-compliant, with a BAA included on every plan. The free plan includes 5 web-app scribe sessions a month with no credit card; Premium is $99/month or $990/year (pricing).
Intake forms and assessments: common questions
What should a therapy intake form include?
A client intake form usually collects contact and emergency contact details, date of birth, insurance or self-pay information, the reason for seeking therapy, current symptoms, past mental health treatment, current medications and prescriber, medical conditions, substance use, family and social background, and the client's goals. The intake packet around it normally adds informed consent for treatment, an acknowledgment of the Notice of Privacy Practices, your fee and cancellation policy, and, where relevant, telehealth consent and a release of information.
What is the difference between an intake form and an intake assessment?
The intake form is what the client completes, usually before the first session. The intake assessment (often called a biopsychosocial assessment) is the clinician's note written after the first session: it pulls together what the client reported, what you observed, the risk assessment, your clinical impressions and diagnosis if any, and the initial plan. The form feeds the assessment; it does not replace it.
What are the sections of an intake assessment?
A common structure is: identifying information, reason for referral and presenting problem, history of the presenting problem, psychiatric and treatment history, medical history and medications, substance use, family history, social, developmental and cultural history, trauma history, strengths and supports, mental status observations, risk and safety, clinical impressions, and recommendations and plan. That is the 14-section structure MentalNote uses for its Intake / Biopsychosocial format.
Do I have to give clients the Notice of Privacy Practices at intake?
Under HIPAA, a covered health care provider with a direct treatment relationship must give the Notice of Privacy Practices no later than the first service delivery and make a good-faith effort to get a written acknowledgment that the client received it (45 CFR 164.520(c)(2)). If the client will not sign, document your effort and the reason.
Do I need a Good Faith Estimate for self-pay clients?
Under the No Surprises Act rules, providers must give uninsured or self-pay clients a Good Faith Estimate of expected charges when a service is scheduled or when the client asks for one (45 CFR 149.610). Many practices include it in the intake packet for self-pay clients. Check the current CMS guidance for timing and content.
How long should an intake assessment be?
Long enough to support the diagnosis, the risk decisions and the treatment plan, and no longer. Mark topics you did not cover as not assessed rather than leaving them blank or filling them with assumptions, and plan to cover them in the next session.
What CPT code is used for a therapy intake?
A psychiatric diagnostic evaluation is usually billed as 90791 (without medical services) or 90792 (with medical services, by a prescriber). Payer rules on frequency and documentation vary; see our guide to 90791 vs 90792 intake documentation.
Can MentalNote write the intake assessment?
MentalNote drafts an intake from the recorded first session (with your client's consent) using its Intake / Biopsychosocial format, with 14 sections. Anything the session did not cover is marked "Not documented in session". It does not fill in your intake forms or consents, and you review and edit every draft before it goes into the record.
Draft the intake from the session.
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