Therapy intake templates help clinicians document initial client information, presenting concerns, history, and treatment planning during the first session.
Part of our therapy notes templates collection.
Client Name: Date: Referral Source: Presenting Concerns: Mental Health History: Medical History: Current Symptoms: Family/Social History: Substance Use History: Client Goals: Risk Assessment: Initial Assessment: Treatment Plan:
Presenting Concerns
Client seeking therapy for anxiety that has worsened over the past three months. Reports difficulty sleeping and persistent worry.
History
No prior therapy. Reports mild anxiety since college. No hospitalizations.
Goals
Reduce anxiety symptoms. Improve sleep quality. Develop coping strategies.
Assessment
Symptoms consistent with generalized anxiety disorder. Client motivated for treatment.
Plan
Weekly CBT sessions. Begin with psychoeducation and cognitive restructuring. Review at 6 weeks.
First therapy session
Initial consultation
New client intake
Transfer of care
Returning clients after gap
Therapists
Counselors
Psychologists
Social workers
Intake coordinators
Standardize initial client documentation
Ensure comprehensive history collection
Reduce intake documentation time
Improve treatment planning
Maintain consistent intake records
Presenting problem and reason for seeking therapy
Mental health and medical history
Risk assessment and safety screening
Client goals for therapy
Informed consent documentation
Family and social context
Document presenting concerns thoroughly
Complete risk assessment
Capture client goals in their words
Include relevant history
Write intake notes promptly
Incomplete history
Missing risk assessment
No treatment goals
Vague presenting concerns
Delayed documentation
No credit card required.
A therapy intake template structures the initial assessment documentation, capturing client history, presenting concerns, goals, and an initial treatment plan.
Intake notes should include presenting concerns, mental health and medical history, current symptoms, client goals, risk assessment, and a preliminary treatment plan.
Intake notes should be completed during or immediately after the initial session to ensure accuracy and thoroughness.
Generate structured therapy notes in minutes — no session recording required.