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Traduire avec GoogleClinical Intake Notes: Template, Examples & What to Include
Complete guide to clinical intake notes for mental health. Includes intake note template, what to include at initial assessment, and new patient documentation.
Principaux points à retenir
- Clinical intake notes establish the T1 baseline for measurement-based care.
- A thorough intake note typically ranges from 400–800 words.
- Standardized screeners like PHQ-9, GAD-7, and PCL-5 should be administered at intake.
- The intake note must document informed consent and the initial treatment plan.
Clinical intake notes (also called initial assessment notes, psychosocial assessments, or new patient documentation) establish the baseline clinical record for a new patient. This guide covers what to include in a mental health intake note, intake note templates, intake assessment examples, and how standardized assessment scores integrate into intake documentation.
What Is a Clinical Intake Note?
A clinical intake note, also called an initial assessment, intake evaluation, or psychosocial assessment, is the detailed clinical record of a patient's first appointment. It establishes the full clinical picture that all subsequent session notes are measured against.
Unlike a progress note, which documents a single therapy session, the intake note covers the patient's entire clinical history: what brought them to treatment now, their psychiatric and medical background, social and developmental context, current functioning, diagnostic impression, and the initial treatment plan.
Standardized screening tools administered at intake, PHQ-9, GAD-7, PCL-5, AUDIT, and others, provide the T1 baseline for measurement-based care. Every subsequent score is compared against this baseline to track treatment response objectively.
Intake Notes vs Progress Notes
| Feature | Intake Note | Progress Note |
|---|---|---|
| Purpose | Establish full clinical baseline | Document ongoing session |
| Length | 400–800 words | 150–350 words |
| History | Full psychiatric, medical, social history | Current session / presenting concerns |
| Assessments | Full battery at T1 baseline | Repeat scores for trend tracking |
| Diagnosis | Initial DSM-5-TR diagnostic impression | Confirm / update existing diagnosis |
| Treatment Plan | Created at intake | Progress toward existing plan |
| Informed Consent | Documented at intake | Not required per session |
What to Include in a Clinical Intake Note
- Presenting Concerns & History of Present Illness: What brings the patient to treatment now. Onset, duration, severity, and precipitating events.
- Psychiatric & Medical History: Prior diagnoses, treatment episodes, medications, allergies, and relevant medical conditions.
- Psychosocial & Developmental History: Family background, educational/employment history, social support, and cultural factors.
- Substance Use History: Current and past use of alcohol, cannabis, and other substances.
- Standardized Assessment Scores (T1 Baseline): PHQ-9, GAD-7, PCL-5, etc., with severity classifications.
- Mental Status Exam (MSE): Observations on appearance, behavior, speech, mood, affect, and thought processes.
- Risk Assessment: Explicit documentation of suicidal ideation, self-harm history, and current risk level.
- Diagnostic Impression & Initial Treatment Plan: DSM-5-TR diagnosis and measurable treatment goals.
- Informed Consent Documentation: Recording that risks, benefits, and confidentiality limits were discussed.
Which Assessment Tools to Administer at Intake
The intake is the most important administration point for standardized tools.
- PHQ-9: Depression (9 items, 3 min)
- GAD-7: Generalized anxiety (7 items, 2 min)
- PCL-5: PTSD / trauma (20 items, 5 min)
- AUDIT: Alcohol use (10 items, 3 min)
- ASRS: Adult ADHD (6 items, 2 min)
- C-SSRS: Suicide risk (6 items, 3 min)
Clinical Intake Note Template
Session Info Date: date | Duration: mins | Modality: In-person / Telehealth | Session type: Initial Assessment / Intake
Reason for Referral / Presenting Concerns Patient is a age-year-old pronouns presenting for brief summary of chief complaint. Patient reports onset, duration, severity.
History of Present IllnessDetailed narrative of current episode: symptoms, functional impact, prior episodes.
Psychiatric & Medical History Psychiatric: prior diagnoses, treatment history, medications. Medical: conditions, medications, allergies. Family history: mental health diagnoses in relatives.
Psychosocial History Developmental: childhood, education. Social: living situation, relationship, social support. Employment: current status. Trauma history: as disclosed.
Substance Use Alcohol: frequency, quantity; AUDIT score. Other substances: DAST-10 score. Tobacco: status.
Standardized Assessments (T1 Baseline)PHQ-9 = __ (severity). GAD-7 = __ (severity). PCL-5 = __. Other: ___.
Mental Status Exam Appearance: appropriate. Behavior: cooperative. Speech: normal. Mood: per patient. Affect: congruent. Thought process: linear. Thought content: no psychosis. Cognition: intact. Insight: good. Judgment: intact.
Risk Assessment Suicidal ideation: denies / passive / active. Self-harm: denies / history. Risk level: Low / Moderate / High. Safety plan: completed / not indicated.
Diagnostic ImpressionICD-11 DSM-5-TR Diagnosis. Clinical impression summary.
Initial Treatment Plan Goal 1: measurable goal. Goal 2: measurable goal. Modality: CBT / supportive. Frequency: weekly. Next session: date. Informed consent obtained: yes.
Frequently Asked Questions
What is a clinical intake note?
A clinical intake note (also called an initial assessment note) documents the first clinical encounter with a new patient. It establishes the baseline clinical picture and becomes the foundation of the entire patient record.
What is the difference between an intake note and a progress note?
An intake note documents the initial assessment and is typically much longer (400–800 words). Progress notes document individual sessions after intake and focus on session content and progress toward the established plan.
Does an intake note include a treatment plan?
Yes. The intake note should conclude with an initial treatment plan including diagnosis, treatment goals, modality, and frequency of sessions.
Does an intake note need to document informed consent?
Yes. The intake is when informed consent for treatment is typically obtained. Documenting that the patient was informed of risks, benefits, and limits of confidentiality is a standard requirement.