[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"guide-en-intake-notes":3},{"doc":4,"fallback":554},{"id":5,"title":6,"author":7,"authorSlug":7,"badge":7,"body":8,"category":536,"color":7,"description":537,"extension":538,"icon":7,"lastReviewed":539,"meta":540,"navigation":541,"path":542,"publishedAt":543,"reviewedBy":544,"seo":545,"slug":546,"stem":547,"subtitle":7,"tags":7,"takeaways":548,"updatedAt":543,"__hash__":553},"guides\u002Fguides\u002Fintake-notes.md","Clinical Intake Notes: Template, Examples & What to Include",null,{"type":9,"value":10,"toc":520},"minimark",[11,15,20,28,31,38,42,157,161,219,223,226,265,269,288,310,318,334,355,372,380,424,444,460,487,491,496,499,503,506,510,513,517],[12,13,14],"p",{},"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.",[16,17,19],"h2",{"id":18},"what-is-a-clinical-intake-note","What Is a Clinical Intake Note?",[12,21,22,23,27],{},"A ",[24,25,26],"strong",{},"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.",[12,29,30],{},"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.",[12,32,33,34,37],{},"Standardized screening tools administered at intake, PHQ-9, GAD-7, PCL-5, AUDIT, and others, provide the ",[24,35,36],{},"T1 baseline"," for measurement-based care. Every subsequent score is compared against this baseline to track treatment response objectively.",[16,39,41],{"id":40},"intake-notes-vs-progress-notes","Intake Notes vs Progress Notes",[43,44,45,62],"table",{},[46,47,48],"thead",{},[49,50,51,56,59],"tr",{},[52,53,55],"th",{"align":54},"left","Feature",[52,57,58],{"align":54},"Intake Note",[52,60,61],{"align":54},"Progress Note",[63,64,65,79,92,105,118,131,144],"tbody",{},[49,66,67,73,76],{},[68,69,70],"td",{"align":54},[24,71,72],{},"Purpose",[68,74,75],{"align":54},"Establish full clinical baseline",[68,77,78],{"align":54},"Document ongoing session",[49,80,81,86,89],{},[68,82,83],{"align":54},[24,84,85],{},"Length",[68,87,88],{"align":54},"400–800 words",[68,90,91],{"align":54},"150–350 words",[49,93,94,99,102],{},[68,95,96],{"align":54},[24,97,98],{},"History",[68,100,101],{"align":54},"Full psychiatric, medical, social history",[68,103,104],{"align":54},"Current session \u002F presenting concerns",[49,106,107,112,115],{},[68,108,109],{"align":54},[24,110,111],{},"Assessments",[68,113,114],{"align":54},"Full battery at T1 baseline",[68,116,117],{"align":54},"Repeat scores for trend tracking",[49,119,120,125,128],{},[68,121,122],{"align":54},[24,123,124],{},"Diagnosis",[68,126,127],{"align":54},"Initial DSM-5-TR diagnostic impression",[68,129,130],{"align":54},"Confirm \u002F update existing diagnosis",[49,132,133,138,141],{},[68,134,135],{"align":54},[24,136,137],{},"Treatment Plan",[68,139,140],{"align":54},"Created at intake",[68,142,143],{"align":54},"Progress toward existing plan",[49,145,146,151,154],{},[68,147,148],{"align":54},[24,149,150],{},"Informed Consent",[68,152,153],{"align":54},"Documented at intake",[68,155,156],{"align":54},"Not required per session",[16,158,160],{"id":159},"what-to-include-in-a-clinical-intake-note","What to Include in a Clinical Intake Note",[162,163,164,171,177,183,189,195,201,207,213],"ol",{},[165,166,167,170],"li",{},[24,168,169],{},"Presenting Concerns & History of Present Illness",": What brings the patient to treatment now. Onset, duration, severity, and precipitating events.",[165,172,173,176],{},[24,174,175],{},"Psychiatric & Medical History",": Prior diagnoses, treatment episodes, medications, allergies, and relevant medical conditions.",[165,178,179,182],{},[24,180,181],{},"Psychosocial & Developmental History",": Family background, educational\u002Femployment history, social support, and cultural factors.",[165,184,185,188],{},[24,186,187],{},"Substance Use History",": Current and past use of alcohol, cannabis, and other substances.",[165,190,191,194],{},[24,192,193],{},"Standardized Assessment Scores (T1 Baseline)",": PHQ-9, GAD-7, PCL-5, etc., with severity classifications.",[165,196,197,200],{},[24,198,199],{},"Mental Status Exam (MSE)",": Observations on appearance, behavior, speech, mood, affect, and thought processes.",[165,202,203,206],{},[24,204,205],{},"Risk Assessment",": Explicit documentation of suicidal ideation, self-harm history, and current risk level.",[165,208,209,212],{},[24,210,211],{},"Diagnostic Impression & Initial Treatment Plan",": DSM-5-TR diagnosis and measurable treatment goals.",[165,214,215,218],{},[24,216,217],{},"Informed Consent Documentation",": Recording that risks, benefits, and confidentiality limits were discussed.",[16,220,222],{"id":221},"which-assessment-tools-to-administer-at-intake","Which Assessment Tools to Administer at Intake",[12,224,225],{},"The intake is the most important administration point for standardized tools.",[227,228,229,235,241,247,253,259],"ul",{},[165,230,231,234],{},[24,232,233],{},"PHQ-9",": Depression (9 items, 3 min)",[165,236,237,240],{},[24,238,239],{},"GAD-7",": Generalized anxiety (7 items, 2 min)",[165,242,243,246],{},[24,244,245],{},"PCL-5",": PTSD \u002F trauma (20 items, 5 min)",[165,248,249,252],{},[24,250,251],{},"AUDIT",": Alcohol use (10 items, 3 min)",[165,254,255,258],{},[24,256,257],{},"ASRS",": Adult ADHD (6 items, 2 min)",[165,260,261,264],{},[24,262,263],{},"C-SSRS",": Suicide risk (6 items, 3 min)",[16,266,268],{"id":267},"clinical-intake-note-template","Clinical Intake Note Template",[12,270,271,274,275,279,280,283,284,287],{},[24,272,273],{},"Session Info","\nDate: ",[276,277,278],"span",{},"date"," | Duration: ",[276,281,282],{},"mins"," | Modality: ",[276,285,286],{},"In-person \u002F Telehealth"," | Session type: Initial Assessment \u002F Intake",[12,289,290,293,294,297,298,301,302,305,306,309],{},[24,291,292],{},"Reason for Referral \u002F Presenting Concerns","\nPatient is a ",[276,295,296],{},"age","-year-old ",[276,299,300],{},"pronouns"," presenting for ",[276,303,304],{},"brief summary of chief complaint",". Patient reports ",[276,307,308],{},"onset, duration, severity",".",[12,311,312,315],{},[24,313,314],{},"History of Present Illness",[276,316,317],{},"Detailed narrative of current episode: symptoms, functional impact, prior episodes.",[12,319,320,322,323,326,327,330,331,309],{},[24,321,175],{},"\nPsychiatric: ",[276,324,325],{},"prior diagnoses, treatment history, medications",". Medical: ",[276,328,329],{},"conditions, medications, allergies",". Family history: ",[276,332,333],{},"mental health diagnoses in relatives",[12,335,336,339,340,343,344,347,348,351,352,309],{},[24,337,338],{},"Psychosocial History","\nDevelopmental: ",[276,341,342],{},"childhood, education",". Social: ",[276,345,346],{},"living situation, relationship, social support",". Employment: ",[276,349,350],{},"current status",". Trauma history: ",[276,353,354],{},"as disclosed",[12,356,357,360,361,364,365,368,369,309],{},[24,358,359],{},"Substance Use","\nAlcohol: ",[276,362,363],{},"frequency, quantity; AUDIT score",". Other substances: ",[276,366,367],{},"DAST-10 score",". Tobacco: ",[276,370,371],{},"status",[12,373,374,377],{},[24,375,376],{},"Standardized Assessments (T1 Baseline)",[276,378,379],{},"PHQ-9 = __ (severity). GAD-7 = __ (severity). PCL-5 = __. Other: ___.",[12,381,382,385,386,389,390,393,394,397,398,401,402,405,406,409,410,413,414,417,418,421,422,309],{},[24,383,384],{},"Mental Status Exam","\nAppearance: ",[276,387,388],{},"appropriate",". Behavior: ",[276,391,392],{},"cooperative",". Speech: ",[276,395,396],{},"normal",". Mood: ",[276,399,400],{},"per patient",". Affect: ",[276,403,404],{},"congruent",". Thought process: ",[276,407,408],{},"linear",". Thought content: ",[276,411,412],{},"no psychosis",". Cognition: ",[276,415,416],{},"intact",". Insight: ",[276,419,420],{},"good",". Judgment: ",[276,423,416],{},[12,425,426,428,429,432,433,436,437,440,441,309],{},[24,427,205],{},"\nSuicidal ideation: ",[276,430,431],{},"denies \u002F passive \u002F active",". Self-harm: ",[276,434,435],{},"denies \u002F history",". Risk level: ",[276,438,439],{},"Low \u002F Moderate \u002F High",". Safety plan: ",[276,442,443],{},"completed \u002F not indicated",[12,445,446,449,452,453,456,457,309],{},[24,447,448],{},"Diagnostic Impression",[276,450,451],{},"ICD-11"," ",[276,454,455],{},"DSM-5-TR Diagnosis",". ",[276,458,459],{},"Clinical impression summary",[12,461,462,465,466,469,470,472,473,476,477,480,481,483,484,309],{},[24,463,464],{},"Initial Treatment Plan","\nGoal 1: ",[276,467,468],{},"measurable goal",". Goal 2: ",[276,471,468],{},". Modality: ",[276,474,475],{},"CBT \u002F supportive",". Frequency: ",[276,478,479],{},"weekly",". Next session: ",[276,482,278],{},". Informed consent obtained: ",[276,485,486],{},"yes",[16,488,490],{"id":489},"frequently-asked-questions","Frequently Asked Questions",[492,493,495],"h3",{"id":494},"what-is-a-clinical-intake-note-1","What is a clinical intake note?",[12,497,498],{},"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.",[492,500,502],{"id":501},"what-is-the-difference-between-an-intake-note-and-a-progress-note","What is the difference between an intake note and a progress note?",[12,504,505],{},"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.",[492,507,509],{"id":508},"does-an-intake-note-include-a-treatment-plan","Does an intake note include a treatment plan?",[12,511,512],{},"Yes. The intake note should conclude with an initial treatment plan including diagnosis, treatment goals, modality, and frequency of sessions.",[492,514,516],{"id":515},"does-an-intake-note-need-to-document-informed-consent","Does an intake note need to document informed consent?",[12,518,519],{},"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.",{"title":521,"searchDepth":522,"depth":522,"links":523},"",2,[524,525,526,527,528,529],{"id":18,"depth":522,"text":19},{"id":40,"depth":522,"text":41},{"id":159,"depth":522,"text":160},{"id":221,"depth":522,"text":222},{"id":267,"depth":522,"text":268},{"id":489,"depth":522,"text":490,"children":530},[531,533,534,535],{"id":494,"depth":532,"text":495},3,{"id":501,"depth":532,"text":502},{"id":508,"depth":532,"text":509},{"id":515,"depth":532,"text":516},"Documentation","Complete guide to clinical intake notes for mental health. Includes intake note template, what to include at initial assessment, and new patient documentation.","md","April 2026",{},true,"\u002Fguides\u002Fintake-notes","2026-02-21","HiBoop",{"title":6,"description":537},"intake-notes","guides\u002Fintake-notes",[549,550,551,552],"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.","0rCJfj_NHtPlNDyuX8eu9ldNoVhbxi8F6dj2ApYl0_E",false]