Intake Note Template for New Therapy Clients

Getting Intake Documentation Right From Session One

The intake session sets the tone for everything that follows — including your documentation. A thorough intake note captures the client's story, your clinical impressions, and the treatment plan you'll build together.

It's also the document auditors scrutinize most closely, because it establishes medical necessity for everything that comes after.

Essential Sections of an Intake Note

A complete intake note typically includes:

That's a lot. A template keeps you organized so nothing falls through the cracks.

Copy & Paste Intake Template

**Presenting Concern:** Client presents for therapy reporting [primary concern]. Symptoms began approximately [timeframe] and are described as [severity/impact on functioning]. Client reports [specific symptoms]. Client's stated goal for therapy: [in client's words].

**History:** Client reports [prior therapy/psychiatric treatment or "no prior treatment"]. Current medications: [list or "none"]. Relevant medical history: [conditions or "no significant medical history"]. Substance use: [pattern or "denies problematic use"]. Family psychiatric history: [relevant or "none reported"].

**Psychosocial:** Client is [age], [relationship status], employed/unemployed as [occupation]. Living situation: [description]. Primary supports: [identify]. Stressors include [list relevant stressors].

**Mental Status Exam:** Appearance: [grooming, attire]. Behavior: [cooperative, guarded, etc.]. Speech: [rate, volume, clarity]. Mood: "[client's words]." Affect: [range, congruence]. Thought process: [linear, tangential, etc.]. Thought content: [no delusions, preoccupations]. Perception: [no hallucinations]. Cognition: [alert, oriented x4]. Insight: [good/fair/poor]. Judgment: [good/fair/poor].

**Risk Assessment:** Suicidal ideation: [denies/endorses — detail if present]. Homicidal ideation: [denies/endorses]. Self-harm history: [detail or denies]. Substance use risk: [assessment]. Protective factors: [list]. Safety plan: [if applicable or "not indicated at this time"].

**Diagnostic Impression:** [Diagnosis code and description, severity specifier]. Rule out: [if applicable].

**Initial Treatment Plan:** Goals: 1) [SMART goal]. 2) [SMART goal]. Interventions: [modality, specific approaches]. Frequency: [weekly/biweekly]. Estimated duration: [timeframe]. Client verbalized understanding and agreement with plan.

Mental Status Exam Quick Reference

If MSE sections trip you up, here's what to capture:

Intake Documentation Tips

Intake notes are the longest documentation you'll write, but they only happen once per client. A solid template makes the process manageable.

For a comprehensive intake note with MSE, risk assessment, diagnostic impression, and treatment plan already structured, TherapistNote can generate a complete draft from the details you enter — so you spend your time reviewing and collaborating with your client, not formatting sections.