Therapy Assessment Template

Last Updated: April 2026

Therapy assessment templates help clinicians document clinical evaluations, diagnostic impressions, and treatment recommendations in a structured format.

Part of our therapy notes templates collection.

Copy-and-Paste Template

Client Name:
Date:
Assessment Type:

Reason for Assessment:

Background Information:

Clinical Observations:

Mental Status Examination:

Diagnostic Impressions:

Functional Assessment:

Strengths and Resources:

Recommendations:

Treatment Plan:

Example

Reason for Assessment

Comprehensive assessment requested following initial intake to clarify diagnostic picture and guide treatment planning.

Clinical Observations

Client presented as cooperative and engaged. Affect anxious. Speech normal rate. Thought process logical and goal-directed.

Diagnostic Impressions

Generalized Anxiety Disorder (F41.1). Rule out Social Anxiety Disorder.

Recommendations

Individual CBT therapy, weekly sessions. Consider medication evaluation if symptoms persist after 8 weeks.

When to Use

  • Initial clinical evaluation

  • Diagnostic clarification

  • Treatment planning

  • Periodic reassessment

  • Pre-treatment assessment

Who Should Use This Template

  • Psychologists

  • Clinical social workers

  • Licensed counselors

  • Psychiatric providers

  • Assessment specialists

Why Use This Template

  • Structure clinical evaluations

  • Support diagnostic decision-making

  • Guide treatment planning

  • Create comprehensive assessment records

  • Facilitate communication with other providers

Types of Clinical Assessments

  • Initial comprehensive assessment

  • Ongoing progress assessments

  • Risk and safety assessments

  • Diagnostic evaluations

  • Functional assessments

Best Practices

  • Include mental status examination

  • Document diagnostic reasoning

  • Note client strengths

  • Provide specific recommendations

  • Connect assessment to treatment planning

Common Mistakes

  • Missing mental status exam

  • No diagnostic reasoning

  • Vague recommendations

  • Incomplete history review

  • Not documenting strengths

Related Templates

Therapy Notes TemplatesTherapy Progress Note TemplateTherapy Session Notes TemplateSOAP Notes TemplateDAP Notes TemplateBIRP Notes Template

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Frequently Asked Questions

A therapy assessment template structures clinical evaluations including mental status examination, diagnostic impressions, and treatment recommendations.

Assessments focus on clinical evaluation and diagnostic formulation, while intake notes capture initial client information and history.

Assessment templates are used by psychologists, clinical social workers, counselors, and psychiatric providers conducting formal clinical evaluations.

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Templates are provided for educational purposes. Always follow your organization's documentation requirements.