Free template

Intake assessment template for therapists

By Albert Wong, PhD, Clinical Psychologist

The intake assessment is the one document in a chart that has to do everything at once: justify a diagnosis, seed the treatment plan, establish the risk baseline, and capture the person — because eighteen months from now, this is the note that explains why treatment ever started. The standard architecture is the biopsychosocial assessment: presenting problem, the relevant histories (psychiatric, medical, substance, family, social, trauma), a mental status exam, risk assessment, diagnostic impressions, and treatment recommendations.

The template below carries all fourteen sections. Use it as a form to fill during and after the first session, or as the outline your intake questionnaire feeds into. It pairs naturally with the treatment plan template — sections 12–14 here are the raw material for the plan.

The template

Plain text — paste into any EHR or document

INTAKE ASSESSMENT (BIOPSYCHOSOCIAL)

Client name: ____________________   Date of service: ____________
Date of birth: __________________   CPT code: ____________
Clinician: ______________________   Location / modality: ____________
Referral source: ________________

1. PRESENTING PROBLEM
The client's chief concern, in their words where useful, and why
they are seeking treatment now:

2. HISTORY OF PRESENTING PROBLEM
Onset, duration, frequency, and severity; precipitating events;
what has helped or worsened it; prior episodes:

3. PSYCHIATRIC & TREATMENT HISTORY
Prior diagnoses, therapy, hospitalizations, and medication trials;
what worked and what didn't:

4. MEDICAL HISTORY & CURRENT MEDICATIONS
Relevant conditions, current medications and prescriber, allergies,
last physical exam, sleep and appetite:

5. SUBSTANCE USE
Alcohol, nicotine, cannabis, other substances, caffeine; current
pattern and history; prior treatment if any:

6. FAMILY HISTORY
Psychiatric and substance-use history in biological relatives;
relevant family medical history:

7. SOCIAL HISTORY
Household and relationships; work or school; culture, religion, and
community; legal history; financial stressors; strengths and
supports:

8. TRAUMA HISTORY
Screen respectfully; detail only what the client is ready to share
and what is clinically necessary at intake:

9. MENTAL STATUS EXAM
Appearance / behavior / speech / mood / affect / thought process /
thought content / perception / cognition & orientation / insight /
judgment:

10. RISK ASSESSMENT
Suicidal ideation (current and history, plan, intent, means, prior
attempts); homicidal ideation; self-harm; protective factors;
safety plan if indicated:

11. MEASURES ADMINISTERED
Instruments and scores (e.g., PHQ-9, GAD-7), if any:

12. DIAGNOSTIC IMPRESSIONS
Diagnosis with ICD-10 code(s); rule-outs; brief rationale tying
symptoms to criteria:

13. CLINICAL SUMMARY & FORMULATION
A short integrative paragraph: who this person is, what is driving
the presenting problem, and what maintains it:

14. TREATMENT RECOMMENDATIONS
Recommended modality, frequency, and initial goals; referrals
(medication evaluation, medical, community); client's response to
the recommendations:

Clinician signature / credentials: ____________  Date signed: ________

A filled example

"Jamie A." is a fictional client — every detail below is invented and deliberately generic. Never copy identifying details from real charts into templates or samples.

Fictional example — for structure, not content

INTAKE ASSESSMENT — FILLED EXAMPLE (fictional client, abridged)

Client name: Jamie A. (fictional)   Date of service: 03/05/2026
Date of birth: 01/01/1990           CPT code: 90791
Clinician: A. Beaumont, PsyD        Location / modality: Office, in person
Referral source: Self-referred (internet search)

1. PRESENTING PROBLEM
Jamie seeks help with "worry that won't switch off," present most
days for about six months and increasing since a job change in the
fall. Wants "tools to stop spinning at night."

2. HISTORY OF PRESENTING PROBLEM
Gradual onset following increased responsibility at work. Worry is
daily, worst in the evening, with muscle tension and difficulty
falling asleep 3-4 nights/week. Denies panic attacks. Exercise and
weekends help; deadlines and unread email worsen it. No prior
episodes of comparable severity.

3. PSYCHIATRIC & TREATMENT HISTORY
Brief counseling in college for adjustment to a move; found it
helpful. No prior diagnoses, hospitalizations, or psychiatric
medications.

4. MEDICAL HISTORY & CURRENT MEDICATIONS
Generally healthy; no current medications; no allergies. Last
physical exam within the past year, unremarkable per client report.
Appetite normal; sleep as above.

5. SUBSTANCE USE
1-2 glasses of wine on weekends; denies tobacco, cannabis, or other
substances. Two coffees daily.

6. FAMILY HISTORY
Reports a parent "who worried a lot"; no known diagnosed psychiatric
or substance-use conditions in the family.

7. SOCIAL HISTORY
Lives with partner; describes the relationship as supportive.
Employed full-time; recent promotion is the primary stressor.
Close friends nearby; enjoys hiking. No legal history; finances
stable. Strengths: motivated, psychologically minded, good support
network.

8. TRAUMA HISTORY
Denies history of abuse or significant trauma on screening.

9. MENTAL STATUS EXAM
Well-groomed, cooperative; speech normal in rate and volume; mood
"stressed," affect mildly anxious and congruent; thought process
linear and goal-directed; no abnormal thought content or perceptual
disturbance; alert and oriented x4; insight and judgment good.

10. RISK ASSESSMENT
Denies current and past suicidal ideation, plan, intent, and
attempts. Denies homicidal ideation and self-harm. Protective
factors: supportive partner, stable work, future orientation. No
safety plan indicated at this time.

11. MEASURES ADMINISTERED
GAD-7: 11 (moderate). PHQ-9: 5 (mild).

12. DIAGNOSTIC IMPRESSIONS
Generalized anxiety disorder (F41.1). Rationale: excessive,
difficult-to-control worry more days than not for over six months,
with tension, sleep disturbance, and functional impact. Rule-out:
adjustment disorder with anxiety (F43.22) if symptoms remit as
work-role adjustment consolidates.

13. CLINICAL SUMMARY & FORMULATION
Jamie is a working adult with a supportive relationship and strong
baseline functioning, presenting with a first sustained episode of
generalized anxiety precipitated by an expanded work role.
Perfectionistic standards and evening rumination appear to maintain
the cycle; motivation and psychological mindedness are notable
assets for treatment.

14. TREATMENT RECOMMENDATIONS
Weekly individual CBT targeting worry and sleep-interfering
rumination; re-administer GAD-7 every 4 weeks. No medication
referral indicated at this time; will revisit if symptoms persist
or worsen. Jamie agreed with the plan and scheduled a first
session.

Clinician signature / credentials: A. Beaumont, PsyD   Date signed: 03/05/2026

Getting the intake right

Baseline measures pay compound interest. A PHQ-9 and GAD-7 at intake cost five minutes and give every future note a number to report progress against — the free PHQ-9 / GAD-7 scorer scores and bands them instantly.
The formulation is the payoff section. Anyone can transcribe a history; section 13 is where you say what it means. Three or four sentences that connect precipitant, maintaining factors, and strengths make the whole document worth reading.
Diagnosis needs a visible rationale. One or two sentences tying symptoms to criteria, plus honest rule-outs. The intake is billed as a diagnostic evaluation — the CPT code picker covers 90791 and the psychotherapy codes that follow it.
For self-pay clients, the intake also triggers Good Faith Estimate duties under the No Surprises Act — our GFE checklist covers what the estimate must contain.

Practice Harbor's intake paperwork and note templates cover this assessment end to end — clients complete the history sections through the portal before the first session, and AI drafting helps turn the interview into the written evaluation for your review and signature.

Common questions

What CPT code is used for a therapy intake?

The psychiatric diagnostic evaluation codes: 90791 for an evaluation without medical services — the code non-prescribing therapists use — and 90792 when medical services (such as prescribing) are part of the evaluation, which is typically psychiatrists and psychiatric NPs. The intake documentation supports this code, which is why intake notes are fuller than progress notes: the evaluation is the service. Payer rules on how often 90791 can be billed per client vary, so check the specific plan.

Do I have to give a diagnosis at intake?

If insurance is paying, effectively yes — claims require a covered ICD-10 diagnosis, and "no diagnosis" is not billable. Clinically, though, you are allowed to be honest about uncertainty: give the best-supported diagnosis, document your rationale, and list rule-outs you are still weighing, as the example above does. For self-pay clients no external rule forces a diagnosis at intake, though many clinicians record diagnostic impressions anyway for continuity of care. What you should not do is reach for a heavier diagnosis than the evidence supports to make something "billable."

Does the intake have to include a mental status exam?

A diagnostic evaluation is expected to include one — the MSE is the observational backbone of the assessment, and its absence is a common documentation finding. It does not need to be long: the ten-line inventory in the template (appearance through judgment) covers the standard domains, and for most outpatient intakes each domain is a few words. Where a domain is abnormal, that is where you slow down and describe.

Can the intake take more than one session?

Clinically, yes — a thorough assessment with a complex history often spreads over two sessions, and rushing it costs you at treatment-planning time. Billing is where it gets payer-specific: some plans reimburse 90791 once per episode of care, others allow it more than once with justification. If your assessment will span sessions, check the plan’s policy; a common pattern is one 90791 followed by psychotherapy codes, with the assessment completed inside those sessions and documented as such.

How much trauma detail belongs in the intake note?

Screen at intake; go deep later, at the client’s pace. The record needs to show that you asked and what you learned at the level of category and clinical significance — not a detailed narrative extracted in the first hour, which can be retraumatizing and is rarely necessary for initial planning. Document what the client shared, note explicitly if they preferred not to elaborate, and let detailed trauma history emerge in treatment when it serves the work.

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This template and guidance are general clinical-documentation education, not legal advice. Assessment and documentation requirements vary by state, license type, and payer contract — check yours.

Notes are half the job. Practice Harbor is an EHR built by a psychologist — intake paperwork, templated notes with AI drafting, and billing that quietly run themselves.

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