Intake notes document initial client information, presenting concerns, and treatment planning during the first session. A thorough intake template helps clinicians capture essential background information while establishing a foundation for treatment.
This guide provides a therapy intake note template, example, and best practices. Part of our therapy notes templates collection.
Client Information: Date: Referral Source: Presenting Concern: History of Present Illness: Mental Health History: Medical History: Social History: Family History: Substance Use History: Current Medications: Mental Status Exam: Risk Assessment: Client Strengths: Client Goals for Therapy: Clinical Assessment: Treatment Plan:
Client: L.P.
Date: April 1, 2026
Referral Source: Primary care physician
Presenting Concerns
Client seeking therapy for anxiety that has worsened over the past six months. Reports difficulty sleeping, persistent worry about health, and avoidance of social situations. Recently started a new job which has increased stress levels.
Mental Health History
No prior therapy. Reports experiencing mild anxiety since adolescence that has not previously required treatment. Denies history of depression, psychosis, or hospitalizations.
Current Symptoms
Difficulty falling asleep (averaging 5 hours/night), racing thoughts, muscle tension, difficulty concentrating at work, avoidance of work social events, and physical symptoms including stomach distress during high-anxiety periods.
Client Goals for Therapy
Client identified three goals: (1) improve sleep quality, (2) reduce worry about health, and (3) increase comfort in social situations at work.
Risk Assessment
No suicidal ideation, homicidal ideation, or self-harm behaviors reported. No access to means concerns. Client denies substance misuse. Safety plan not indicated at this time.
Initial Clinical Assessment
Symptoms consistent with Generalized Anxiety Disorder with social anxiety features. Onset correlated with occupational transition. Client demonstrates good insight and motivation for treatment.
Preliminary Treatment Plan
CBT-based treatment targeting anxiety management. Begin with psychoeducation and cognitive restructuring. Introduce sleep hygiene strategies. Consider graded exposure for social situations. Weekly sessions recommended. Reassess progress at 6 weeks.
Establish a clinical baseline for treatment
Identify risk factors and safety concerns early
Guide treatment planning and goal-setting
Improve continuity of care across providers
Document presenting concerns and history for the clinical record
Support insurance authorization and medical necessity
Therapists conducting initial assessments
Counselors starting with new clients
Psychologists in private practice
Behavioral health intake coordinators
Social workers in clinical settings
Psychiatric providers
First therapy session with a new client
Initial consultation or assessment
When a client transfers from another provider
When resuming treatment after a significant gap
Psychiatric intake evaluations
Presenting concerns and reason for seeking therapy
Mental health and treatment history
Medical history and current medications
Family and social history
Current symptoms and functional impact
Substance use history
Client goals for therapy
Risk assessment
Initial clinical assessment and diagnostic impressions
Preliminary treatment plan
Be thorough but organized — use a consistent template
Document client goals in their own words where possible
Complete risk assessment documentation
Include enough history for treatment planning
Note referral source and reason for seeking treatment
Write intake notes promptly after the initial session
Missing client goals for therapy
Incomplete mental health or medical history
No risk assessment documentation
Missing or vague treatment plan
Not documenting referral source
Delaying intake documentation
AI-assisted documentation can help structure intake information from brief session summaries.
No credit card required.
A therapy intake note documents initial client information gathered during the first session, including presenting concerns, relevant history, current symptoms, treatment goals, and an initial assessment and treatment plan.
Intake notes should include presenting concerns, relevant personal and mental health history, current symptoms, client goals for therapy, an initial clinical assessment, and a preliminary treatment plan.
Intake notes should be completed during or immediately after the initial consultation or first therapy session. Writing promptly ensures accuracy and thoroughness.
Yes. Intake notes are written at the start of treatment and capture comprehensive background information. Progress notes are written after each subsequent session and track ongoing treatment. Intake notes are typically more detailed.
Many clinical settings require a mental status exam as part of the intake assessment. This includes observations about appearance, behavior, mood, affect, thought process, cognition, and judgment.
Intake notes are typically more comprehensive than progress notes and may take 15-30 minutes to complete. Using a structured template helps ensure thoroughness while reducing documentation time.
Generate structured therapy notes in minutes — no session recording required.