Best for
- Initial individual psychotherapy encounters
- Clinicians creating a consistent intake workflow
- Practices that need assessment findings tied directly to a first treatment plan
Assessment template
Therapy Intake Assessment Template
A therapy intake assessment establishes why the client is seeking care, the relevant history and current clinical picture, initial risk findings, strengths and preferences, diagnostic impressions, and a collaborative first plan.
What makes this format different
An intake assessment prioritizes the decisions needed to begin care. A biopsychosocial assessment may cover more domains in greater depth, while an intake can remain focused on immediate presentation, safety, formulation, and next steps.
Copy and adapt
Blank Intake template
Identification information Reasons for seeking therapy Psychotherapeutic goals Relevant medical and psychiatric history Psychosocial history Risk assessment Current mental and functional status Diagnostic information Initial treatment plan SNAP: strengths, needs, abilities, preferences ICD-10 code(s), if supported [For missing domains, state “not assessed,” “client declined,” or “additional assessment needed” rather than guessing.]
Adapt required fields to your license, setting, payer, EHR, jurisdiction, and organization policy. Do not use a generic template as a compliance checklist.
Prompt architecture
How to write each section prompt
A useful section prompt tells the writer what evidence belongs in the section, where the information comes from, and what must not be inferred. The prompts below are adapted from BeeThere’s production note-format definitions.
1
Presenting concerns and goals
Capture the client’s priorities and the impact that led them to seek care.
Section prompt
Summarize the primary concerns, symptoms, stressors, onset and course, functional impact, desired outcomes, strengths, motivation, and what the client hopes therapy will change.
Include
- Reason for seeking care
- Impact
- Client-defined goals
Guardrail
Avoid converting the client’s language into a diagnosis before completing the assessment.
Fictional section example
The client seeks help for increasing worry, sleep difficulty, and work avoidance. They want to respond to stress with less rumination and regain consistency at work.
2
Relevant history and current status
Gather the background necessary for safe and appropriate initial planning.
Section prompt
Summarize relevant medical, psychiatric, medication, substance, family, developmental, relational, social, cultural, trauma, education, work, and legal history. Document current mental status, functioning, strengths, and observed presentation.
Include
- Relevant history
- Current functioning
- Mental status observations
Guardrail
Avoid presenting unverified history as established fact; attribute it to the client or source.
Fictional section example
The client reported prior short-term therapy, no hospitalization, and a stable medical condition managed by primary care. They were fully oriented, cooperative, and visibly tense when discussing work.
3
Risk assessment
Document current and historical risk findings and the response they require.
Section prompt
Record suicidal and homicidal ideation, self-harm, violence, abuse or neglect concerns, substance-related risk, relevant history, access or intent when assessed, protective factors, overall risk level, and actions taken. Use only assessed information.
Include
- Current and historical findings
- Protective factors
- Clinical action
Guardrail
Never generate or assume a negative risk finding. Escalate according to policy when indicated.
Fictional section example
The client denied current suicidal or homicidal ideation when asked and reported no self-harm history. Protective factors include family connection and future goals. No acute intervention was indicated.
4
Diagnostic information and initial plan
State a supported working formulation and the next assessment or treatment steps.
Section prompt
Summarize diagnostic impressions, supporting symptoms, impairment, reasonable differentials, and areas needing more assessment. Use a provisional diagnosis when appropriate. Connect the formulation to initial goals, interventions, frequency, referrals, and coordination.
Include
- Evidence and uncertainty
- Initial level or frequency of care
- Next assessment needs
Guardrail
Do not assign an unsupported diagnosis or ICD-10 code to complete the form.
Fictional section example
The current presentation suggests an anxiety disorder; additional assessment is needed to clarify duration and differential diagnoses. Begin weekly CBT-oriented therapy and obtain consent for coordination with primary care if needed.
5
SNAP
Make the plan collaborative and responsive to the client’s resources and preferences.
Section prompt
Document strengths, needs, abilities, and preferences that will affect engagement, intervention choice, accessibility, and treatment planning.
Include
- Strengths
- Practical or clinical needs
- Preferences and abilities
Guardrail
Avoid treating client preferences as resistance.
Fictional section example
Strengths include insight and supportive family. The client needs evening appointments, prefers structured exercises, and is able to use secure telehealth.
Fully fictional
Completed Intake example
This fictional intake example is intentionally brief. Intake requirements vary by license, setting, payer, jurisdiction, and organizational policy.
Presenting concerns and goals
The client seeks help for increasing worry, sleep difficulty, and work avoidance. They want to respond to stress with less rumination and regain consistency at work.
Relevant history and current status
The client reported prior short-term therapy, no hospitalization, and a stable medical condition managed by primary care. They were fully oriented, cooperative, and visibly tense when discussing work.
Risk assessment
The client denied current suicidal or homicidal ideation when asked and reported no self-harm history. Protective factors include family connection and future goals. No acute intervention was indicated.
Diagnostic information and initial plan
The current presentation suggests an anxiety disorder; additional assessment is needed to clarify duration and differential diagnoses. Begin weekly CBT-oriented therapy and obtain consent for coordination with primary care if needed.
SNAP
Strengths include insight and supportive family. The client needs evening appointments, prefers structured exercises, and is able to use secure telehealth.
Quality check
Common documentation mistakes
- Assigning a diagnosis before enough information is available
- Using prefilled negative risk statements
- Documenting every life detail instead of relevant history
- Omitting the client’s goals and preferences
- Failing to distinguish client report from observation
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