What is a Therapy Intake Note & How Should I Write one?

If you're a mental health clinician, documenting client intake appointments is an essential first step that you will frequently encounter. A therapy intake occurs in the first appointment, where you gather background information about your client. The questions you ask in the first appointment with a new client help you understand the client's presenting problems and find targets and symptoms to focus on in future therapy sessions.

What questions a therapist asks in the first appointment may differ from one therapist to another. With all the information you gather in the first appointment, knowing what you should ask or include in an intake note may be challenging.

What are Intake Notes?

Intake notes are a type of note used specifically in psychotherapy settings and mental health. They include detailed information about the mental health history of the client, current symptoms and concerns, as well as personal and social history, family history, and any previous treatment received.

They serve as a comprehensive starting point for the mental health professional to understand the client's current situation and to plan and provide appropriate therapy.

What's different about intake notes?

When you meet with a client for the first time, you gather background information and outline policies and procedures for the therapy process. Therefore, your documentation of the first session may look different than documenting a note for an established client.

Some psychotherapists gather most of the background information from forms or assessments their clients fill out before engaging in therapy; others prefer to do evaluations or collect biopsychosocial details in the first session.

The information you review may look much different in your first session. You may include information in your documentation of an intake appointment, such as:

• Limits of confidentiality
• Payment procedures
• Telehealth procedures
• Contact outside of the session
• Risks and benefits of therapy
• Cancellation policies

Clients often sign a document called "informed consent" before engaging in therapy. However, for some clinicians, reviewing policies and procedures verbally before engaging in the therapeutic process is still helpful.

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TIP: The Mentalyc AI Note-Taking app is a great option for therapists that are looking for a way to save time when writing notes. This app transcribes sessions into progress notes and can be used on any device. It also helps to reduce the amount of time spent manually typing out notes, as well as reducing the chances of errors in the note-taking process.

This app is perfect for all sorts of mental health therapies, specially those that typically requires more detailed and precise progress notes. The Mentalyc app is an effective way to create professional and accurate progress notes quickly and with less effort, allowing psychotherapists to focus their energy on providing quality care to their clients.

What information is in an intake note?

In addition to reviewing policies and procedures that you might document in an intake progress note, you may also gather relevant client history.

Typical information that psychotherapists may record in an intake progress note includes:

• Reasons for coming to therapy
• Previous experiences with therapy
• How current problems are affecting the client
• Medical history
• Current medications
• Substance use history
• Any previous mental health diagnoses
• Mental health history (including hospitalizations, SI, HI)
• Family history
• Employment
• Trauma history
• Education History
• Cultural background
• Support system
• Any assessments they've taken
• Legal history
• Strengths
• Religious/Spiritual concerns
• Mental Status Exam

Each psychotherapist may include differing background information in their intakes; however, these are some common areas of focus for clinicians.

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Common challenges with intake notes

When you document a therapy intake appointment, it may be difficult to condense all the information you have gathered from your client in an organized way. In addition, intake appointments sometimes take more than one session to gather the necessary information, complicating documentation further.

Another challenge when writing an intake progress note is that you have often sent forms to your client to have them fill out before the session. You may be gathering information in the intake appointment based on data you already have documented. It may be unnecessary to repeat the same information in your intake note.

Dealing with intake note pitfalls

If you're finding it challenging to record your intake appointments, here are some tips to make this process easier.

• Use an intake progress note template
• Record the information your client states in the first session
• Don't record unnecessary information you already gathered in the intake packet
• Check applicable laws and regulations in your state for what should be included in an intake
• Document the minimum necessary to collect the complete picture

Many electronic health record systems offer templates for psychotherapy intakes. You can find many templates online for your first appointment with a client if you're at a complete loss for where to begin and what information you need.

A thorough intake packet will help limit the mass amounts of information you will need to document during the first appointment.

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Helpful questions to ask when writing an intake note

We've identified that intake notes differ from other progress notes because the client tells you relevant background information in the first session.

Here are some helpful questions you can ask yourself to help with recording your first session:

• Did I review relevant practice policies and procedures with my client?
• Does my client understand the limits of secrecy?
• Does my client understand my financial policies?
• Did I review the risks and benefits of therapy with my client?
• Why is the client here?
• What does the client want to work on?
• Have they been in treatment before?
• What were their previous therapy experiences like?
• What have they tried to help with their current presenting problem or problems?
• What kind of support does my client have?
• What cultural background and experiences of my client are relevant to their case?
• What kind of medical history does my client have?
• What medications is the client currently taking?
• What relevant spiritual or religious background is important to my client?
• Is my client experiencing suicidal or homicidal thoughts?
• Does my client have any problems with substance use?
• Does my client have a relevant legal history?
• What are my client's current stressors?

These questions can be a good starting point for conceptualizing a case and formulating an intake document. While these aren't all-encompassing, they can help you understand important and relevant parts of the client's background.

Why is the intake appointment necessary?

The intake appointment and documentation set the framework for therapy. First, you're gathering client history to get the complete picture of your client's life and formulate a treatment plan.

The background information helps you learn about your client's strengths, needs, wishes, and desires for therapy. You can use the client's strengths to help them build their skills in treatment. You also get a clear idea of their obstacles to obtaining the life they want.

The intake appointment sometimes takes multiple sessions, so you can document each relevant piece of their history in separate notes when you complete each intake session.

Intake Forms

Intake forms before therapy begins are essential. As previously stated, having intake forms the client fills out before treatment is helpful because they provide crucial background information. You can ask clarifying questions in the intake appointment to build off of the information your client provided in their intake forms.

Here are some necessary forms to include in your intake packet:

• Informed consent
• Fee policy
• Release of information form
• Notice of privacy practices
• Telehealth agreement
• Client contact information form
• Emergency contact information
• Good Faith Estimate

In your intake packet, your contact information form should include information such as the following:

• Client's full name
• Client's date of birth
• E-mail address
• Phone number
• Insurance information (if applicable)
• Allergies
• Pronouns
• Emergency contacts

In your informed consent, you explain policies such as:

• Limits of secrecy
• Cancellation policies
• Financial Policies
• Risks and benefits of therapy
• How to reach your psychotherapist between sessions
• Background information about the psychotherapist
• Court fees
• Telehealth information (if applicable)
• Information about dual relationships
• Gift-giving policies
• What services do you provide
• What states you're licensed in

This information can also be verbally discussed in the first session. Even if your client has signed off on your policies and procedures, they may still have questions about therapy or your policies and procedures in the first session. Reviewing these to ensure the client understands and is fully informed about your systems is essential.

If you do review this information in your first session with the client, you can also document this in your intake document.

This documentation may look something like this:

"The psychotherapist reviewed the limits of confidentiality with the client in the intake session and also reviewed relevant therapy policies and procedures. The client voiced understanding and asked a few questions about the practice's financial policies, and the psychotherapist clarified this policy for them."

Sample Intake Note Example

The client presented for a first-time teletherapy appointment on 1/1/2023. The client is alert and oriented to the session. The client appears anxious, and they are well-dressed. The therapist first reviewed the limits of secrecy with the client and answered any questions they had from the informed consent documents. The client voiced an understanding of all therapy policies and procedures and the limits of confidentiality.

The client presents for therapy due to generalized anxiety. They report that they have experienced increased anxiety for the past three months, and they haven't previously sought help for it. They state this is their first time in therapy. The client says they're having increased panic attacks and difficulty giving presentations at work, which is a large part of their job responsibilities.

The client occasionally uses alcohol to help them reduce their anxiety, but they report that this only helps in the short term, and they would like to learn healthier skills to cope with their anxiety. They state that this is their only mental health concern at this time.

The client denies any previous mental health hospitalizations and denies any suicidal ideation. The client also denies a history of suicidal ideation or self-harm.

The client reports that both of her parents have a history of anxiety but never received treatment for it. In addition, the client is employed in a corporate job, which causes them high stress. The client reports she is close to her parents and her sister. She mentions she has two close friends who she sees often.

The therapist educated the client that in the subsequent two sessions, they would continue gathering background information and setting goals for therapy based on the anxiety they are experiencing. The client voiced understanding, and the therapist will continue to collect background information from the client in future sessions. The therapist and client planned to meet again for an appointment next Wednesday at 10 a.m.

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About the author

Marissa Moore

Marissa Moore is a mental health professional who owns Mending Hearts Counseling in Southwest Missouri. She specializes in providing affirming counseling services to the LGBTQIA+ community. Marissa has 11 years of experience working in the mental health field, and her work experience includes substance use treatment centers, group homes, an emergency room, and now private practice work.

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