Intake notes document the initial assessment of a new client, capturing presenting concerns, history, risk factors, and treatment planning. These examples demonstrate how to write thorough intake documentation across different levels of clinical complexity.
Part of our therapy notes examples guide.
Therapists conducting initial intake assessments with new clients
Private practice clinicians building intake documentation workflows
Community mental health and hospital-based clinicians requiring comprehensive assessments
New therapists learning to write thorough intake evaluations
Identifying Information
32-year-old female, self-referred, employed full-time as a marketing manager. Lives with partner. No children. No prior therapy history.
Presenting Concerns
Client reports persistent worry and anxiety over the past six months, primarily related to work performance and social situations. Describes difficulty controlling worry, muscle tension, restlessness, and disrupted sleep (taking 45-60 minutes to fall asleep most nights). Reports avoiding presentations at work and declining social invitations due to anticipatory anxiety. GAD-7 score: 15 (moderate-to-severe anxiety).
Relevant History
No prior mental health treatment. Reports anxiety has been present at lower levels since college but worsened significantly after a promotion six months ago. Denies history of panic attacks. No significant medical history. No current medications. Family history notable for mother with generalized anxiety (untreated). No substance use concerns. No history of trauma reported.
Risk Assessment
Denies suicidal ideation, homicidal ideation, and self-harm. No history of suicide attempts. No access to firearms. Protective factors include supportive partner, stable employment, and motivation for treatment. Risk level: low.
Clinical Impressions
Presentation consistent with Generalized Anxiety Disorder (F41.1). Client meets DSM-5-TR criteria including excessive worry, difficulty controlling worry, and associated somatic symptoms persisting for more than six months with functional impairment in occupational and social domains.
Treatment Plan
1) Individual therapy, weekly, 50-minute sessions. 2) CBT with focus on cognitive restructuring and behavioral experiments for anxiety. 3) Introduce relaxation training (progressive muscle relaxation, diaphragmatic breathing). 4) Gradual exposure to avoided situations (presentations, social events). 5) Readminister GAD-7 every four sessions to track progress. 6) Goals: reduce GAD-7 to mild range (<10), resume social activities, deliver one work presentation within 8 weeks.
Identifying Information
45-year-old male, referred by PCP Dr. Martinez for depressive symptoms. Employed as a high school teacher. Divorced, lives alone. Two children (ages 12 and 15) with shared custody. Referred after routine screening at annual physical.
Presenting Concerns
Client reports persistent depressed mood, anhedonia, and fatigue over the past three months following his divorce finalization. Describes feeling 'empty' and 'going through the motions.' Reports significant sleep disturbance with early morning awakening (3:00-4:00 AM) and inability to return to sleep. Appetite decreased with unintentional weight loss of approximately 8 pounds over two months. Concentration difficulties affecting work performance — reports difficulty grading papers and preparing lesson plans. PHQ-9 score: 19 (moderately severe depression). Endorses passive suicidal ideation: 'Sometimes I think everyone would be better off without me,' but denies active ideation, intent, or plan.
Relevant History
Prior therapy history: attended 12 sessions of individual therapy during separation approximately 18 months ago, reported it as 'somewhat helpful.' No prior psychiatric hospitalization. Previous depressive episode in his late 20s that resolved without treatment after approximately four months. Family history significant: father completed suicide at age 52, mother had recurrent depression treated with SSRIs. Currently prescribed sertraline 50mg by PCP, started three weeks ago with no notable side effects or improvement yet. No substance abuse history, reports occasional alcohol use (2-3 drinks per week, no change). No illicit drug use. Medical history: hypertension managed with lisinopril.
Risk Assessment
Passive suicidal ideation present without intent, plan, or preparatory behavior. History of paternal suicide is a significant risk factor. No personal history of suicide attempts. Denies homicidal ideation. Denies access to firearms. Protective factors: children (described as 'my reason for being here'), stable employment, engagement with PCP, willingness to attend therapy, and prior positive therapy experience. Safety plan developed collaboratively in session including crisis contacts (sister, crisis line 988), coping strategies, and means restriction discussion. Risk level: moderate (chronic risk factors with low acute risk).
Clinical Impressions
Major Depressive Disorder, recurrent episode, moderate-to-severe (F33.2). Current episode precipitated by divorce finalization and adjustment to living alone. Significant family history of depression and completed suicide increases chronic risk. Current sertraline trial is early (three weeks) and may require dosage adjustment. Client demonstrates fair insight into depressive symptoms and their connection to life stressors. Motivation for treatment is present, supported by desire to be present for his children.
Treatment Plan
1) Individual therapy, weekly, 50-minute sessions. 2) CBT for depression with behavioral activation as initial focus. 3) Coordinate with PCP Dr. Martinez regarding sertraline response and potential dosage adjustment at 6-week mark. 4) Behavioral activation schedule: identify two pleasurable activities per week and one social connection. 5) Readminister PHQ-9 every two sessions. 6) Review and update safety plan at each session. 7) Monitor passive SI closely; if ideation intensifies or becomes active, initiate crisis protocol. 8) Goals: reduce PHQ-9 to mild range (<10), establish consistent sleep routine, resume social connections, maintain occupational functioning. 9) Reassess treatment progress at session 8.
Identifying Information
28-year-old nonbinary client (they/them pronouns), self-referred, employed part-time as a freelance graphic designer. Lives alone in an apartment. Single, no children. Reports previous therapy experiences with three different therapists over the past five years, each lasting 3-6 months before discontinuation.
Presenting Concerns
Client reports chronic emotional dysregulation, difficulty maintaining relationships, and intrusive memories related to childhood emotional abuse and neglect. Describes frequent dissociative episodes ('zoning out for minutes at a time, losing track of conversations'), nightmares 3-4 times per week, and persistent feelings of shame and worthlessness. Reports difficulty trusting others and a pattern of idealizing then devaluing relationships. Current cannabis use: daily, 1-2 times per day, described as 'the only thing that helps me sleep.' PCL-5 score: 38 (above clinical threshold of 33). DES (Dissociative Experiences Scale) score: 18 (elevated but below the clinical threshold of 30 for dissociative disorder). PHQ-9: 14 (moderate depression). Client reports one psychiatric hospitalization at age 22 for suicidal crisis following a relationship breakup.
Relevant History
Childhood history significant for emotional abuse and neglect by primary caregiver (mother), including chronic criticism, unpredictable emotional availability, and parentification (caring for younger siblings from age 8). Father was largely absent. No reported physical or sexual abuse. First sought therapy at age 23. Previous treatment modalities included supportive therapy and brief CBT; client reports these were 'not deep enough' and terminated when therapists 'didn't get it.' One psychiatric hospitalization at age 22: 5-day inpatient stay following suicidal ideation with plan (overdose) after relationship dissolution. No suicide attempts. Prescribed quetiapine 50mg PRN for sleep by previous psychiatrist; client reports inconsistent use. Cannabis use began at age 20, escalated to daily use over the past two years. Denies other substance use. Medical history: no significant conditions. Family history: mother suspected untreated personality disorder, maternal grandmother had depression, father's history unknown.
Risk Assessment
No current suicidal ideation. History of one suicidal crisis with ideation and plan (age 22) requiring hospitalization. No suicide attempts. Denies homicidal ideation or intent to harm others. Self-harm history: superficial cutting ages 16-20, reports cessation for past 8 years. Dissociative symptoms present but do not appear to involve identity alteration or amnesia for significant events. Cannabis use is a risk factor for emotional avoidance and may complicate treatment. Protective factors: employment, creative outlets, motivation to understand relational patterns, and intellectual engagement with therapy process. Risk level: moderate (chronic risk factors; low acute risk currently).
Clinical Impressions
Complex Posttraumatic Stress Disorder (proposed ICD-11 criteria met; coded as PTSD F43.10 with additional features per DSM-5-TR). Client meets criteria for PTSD related to chronic childhood emotional abuse with additional features of affect dysregulation, negative self-concept, and interpersonal disturbances consistent with complex trauma sequelae. Dissociative features present (DES: 18) but do not meet threshold for a separate dissociative disorder diagnosis at this time. Rule out Borderline Personality Disorder — relational instability and emotional dysregulation are present but appear trauma-driven rather than characterological, warranting further assessment. Cannabis Use Disorder, mild (F12.10) — daily use with functional impact and failed attempts to reduce. Moderate depressive symptoms likely secondary to trauma and relational difficulties.
Treatment Plan
1) Individual therapy, weekly, 50-minute sessions, with phase-oriented trauma treatment approach. 2) Phase 1 (Stabilization, sessions 1-12): establish therapeutic alliance, develop distress tolerance and emotion regulation skills using DBT-informed interventions, grounding techniques for dissociative episodes, and psychoeducation on complex trauma. 3) Phase 2 (Processing, sessions 13+): initiate trauma processing using CPT or EMDR once stabilization criteria are met (reduced dissociation, consistent emotion regulation skill use, stable therapeutic alliance). 4) Schema therapy interventions for core beliefs related to defectiveness and mistrust as treatment progresses. 5) Address cannabis use through motivational interviewing; explore harm reduction as initial goal. 6) Refer to psychiatry for medication evaluation (current quetiapine PRN use is inconsistent; may benefit from structured medication management). 7) Readminister PCL-5, DES, and PHQ-9 every six sessions. 8) Safety plan in place; review at each session during Phase 1. 9) Goals: reduce PCL-5 below clinical threshold, develop three consistent emotion regulation strategies, establish one stable interpersonal connection, reduce cannabis use to non-daily. 10) Reassess diagnostic impressions and treatment plan at session 12.
Intake notes serve as the clinical foundation for treatment. They establish the baseline against which all future progress is measured and provide the rationale for your treatment approach.
First session with new clients entering therapy
Program admissions and clinical onboarding assessments
Re-evaluations when a client returns after a gap in treatment
Comprehensive biopsychosocial assessments and initial evaluations
Therapists and counselors conducting initial client assessments
Clinical social workers performing psychosocial evaluations
Psychologists completing comprehensive intake batteries
Intake coordinators at clinics, hospitals, and treatment centers
Establishes the clinical baseline against which all future progress is measured
Guides treatment planning by connecting assessment findings to interventions
Satisfies insurance pre-authorization requirements with documented medical necessity
Provides essential context for continuity of care if the client transfers providers
Client is a 29-year-old female, self-referred for anxiety. GAD-7: 14. Reports persistent worry, sleep difficulty, and work avoidance for 3 months. Denies SI/HI/SH. No prior treatment. Dx: GAD (F41.1). Recommend weekly CBT, 12 sessions. Client agrees.
Client is a 41-year-old male, referred by PCP for depression. PHQ-9: 17 (moderately severe). Reports 6 months of low mood, anhedonia, weight loss (8 lbs), and early morning awakening. Currently on sertraline 50mg with partial response. Passive SI ("sometimes wish I could just sleep forever") without plan or intent. Family history: father with MDD, maternal aunt completed suicide. Protective factors: supportive wife, two children, employment, religious community. Safety plan developed. Dx: MDD, recurrent, moderate (F33.1). Recommend weekly CBT + behavioral activation, coordinate with PCP re: sertraline dosage increase. Client agrees with treatment plan.
See how intake notes compare with other common therapy documentation formats.
| Format | Best For | Key Sections | Pros |
|---|---|---|---|
| Intake Notes | First sessions, comprehensive assessments, establishing baselines | Presenting concerns, history, risk assessment, diagnosis, treatment plan | Thorough clinical foundation; supports insurance pre-auth; guides entire treatment course |
| SOAP Notes | Ongoing session documentation, medical settings | Subjective, Objective, Assessment, Plan | Structured and familiar; widely accepted by insurers; easy to review |
| DAP Notes | Session documentation with clinical interpretation | Data, Assessment, Plan | Simpler structure; focuses on clinical reasoning; efficient for experienced clinicians |
| Progress Notes | Tracking treatment progress over time | Session focus, interventions, response, plan | Flexible format; tracks change across sessions; adaptable to any modality |
Follow these best practices to write intake notes that are thorough, clinically sound, and set the stage for effective treatment.
Establish a thorough baseline — document current symptom severity with standardized measures, functional impairment, and relevant history to enable meaningful progress tracking
Use clinical language consistently — write with professional terminology that supports diagnostic reasoning, treatment planning, and insurance documentation
Always include a risk assessment — screen for suicidal ideation, homicidal ideation, self-harm, and access to means regardless of the presenting concern, and document your findings
Specify measurable treatment goals — connect your treatment plan to the assessment findings with specific, observable goals, interventions, and a timeline for reassessment
Incomplete risk assessment
Failing to document suicidal ideation screening, homicidal ideation, self-harm history, or access to means. Every intake note must include a thorough risk assessment regardless of presenting concern, with clear documentation of risk level and safety planning if indicated.
Too much irrelevant detail
Including extensive social history or background information that does not inform the clinical conceptualization or treatment plan. Focus on clinically relevant history that directly connects to the presenting concerns, diagnostic formulation, and treatment approach.
Missing treatment plan
Completing a thorough assessment without documenting a clear treatment plan with specific interventions, frequency, measurable goals, and timeline for reassessment. The treatment plan is the clinical roadmap and should flow logically from the assessment findings.
Vague diagnostic impressions
Writing generic impressions like 'client presents with anxiety and depression' without specifying diagnostic criteria met, severity, provisional vs. confirmed status, or rule-out diagnoses. Diagnostic impressions should demonstrate clinical reasoning and support treatment decisions.
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A comprehensive intake note should include identifying information, presenting concerns, symptom history and duration, relevant medical and psychiatric history, family and social history, substance use screening, risk assessment (suicidal ideation, homicidal ideation, self-harm), mental status examination, clinical impressions or diagnostic formulation, and an initial treatment plan with goals.
An intake note typically takes 20-45 minutes to write, depending on complexity. The initial intake session itself usually runs 60-90 minutes. Using structured templates or AI documentation tools can reduce writing time significantly while ensuring all required sections are covered.
Yes, intake notes should include diagnostic impressions, even if provisional. Document the rationale for your diagnostic conclusions, including which criteria are met and any rule-out diagnoses. If a formal diagnosis is deferred pending additional information, document that clearly along with your clinical reasoning.
An intake note is a comprehensive initial assessment that establishes the baseline for treatment, including full history, diagnostic formulation, and treatment planning. Progress notes document individual sessions and track ongoing treatment. Intake notes are typically much longer and more detailed, covering areas that progress notes reference but do not repeat in full.
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