A therapy intake assessment gathers what you need at the first session to understand the client, judge risk, and agree on a plan. Copy the free template, see an adult low mood and a young adult alcohol use example, and check what to cover in each part.
Blank therapy intake assessment template
FreeTHERAPY INTAKE ASSESSMENT Client: [Name, age, pronouns] Date of assessment: [Date] Format: [In person, video, or phone; client's location if remote] Referral source: [Self, physician, school, employer, or other] Others present: [Name and relationship, or none] Clinician: [Name, credentials] CONSENT AND CONFIDENTIALITY Informed consent: [Consent to assessment and treatment discussed and signed] Limits of confidentiality: [Exceptions that apply where you practice, explained: serious risk of harm, suspected child abuse, court order] Recording: [Consent to audio recording or an AI scribe, or none used] Client questions: [What the client asked, and your answers] REASON FOR REFERRAL Presenting problem: [The main concern, in the client's words] History of the problem: [Onset, duration, triggers, course, what has helped] Current impact: [Effect on work or school, relationships, sleep, self-care] Client's goals: [What the client hopes will change] HISTORY Psychiatric history: [Past diagnoses, therapy, medications, hospital stays, past suicide attempts or self-harm] Medical history: [Conditions, current medications, allergies, primary care clinician] Substance use: [Alcohol, cannabis, nicotine, other drugs: amount, frequency, last use, consequences, withdrawal] Trauma screen: [Asked in general terms; what the client chose to share] FAMILY AND SOCIAL Family history: [Mental health and substance use problems in relatives] Household and relationships: [Who the client lives with, partner, children, close supports] Work, school, and finances: [Current role, performance, money worries] Culture and identity: [Language, faith, and cultural factors the client names] Strengths: [Skills, interests, past coping that worked] RISK ASSESSMENT Suicide: [Ideation, plan, intent, preparation, past attempts] Access to means: [Firearms, stored medications, other means] Self-harm and harm to others: [Current or past, with details] Safety at home: [Abuse, neglect, or violence] Protective factors: [Reasons for living, supports, engagement] Risk formulation: [Your judgment of current risk, the reasons, and the safety plan if indicated] MENTAL STATUS AND SCREENING Appearance and behavior: [Dress, hygiene, eye contact, movements, rapport] Speech, mood, and affect: [Rate and volume; mood in the client's words; affect observed] Thought and perception: [Process, content, hallucinations] Cognition, insight, and judgment: [Orientation, attention, memory; insight and judgment] Screening measures: [PHQ-9, GAD-7, PCL-5, AUDIT, or others, with scores] IMPRESSION AND RECOMMENDATIONS Diagnostic impression: [Working diagnosis and the features that support it] Differential and medical factors: [Other diagnoses considered; medical causes to rule out] Recommended care: [Level of care, approach, frequency, expected length] Referrals: [Psychiatry, primary care, substance use services, or other] Initial goals: [Two or three goals agreed with the client] Next appointment: [Date and format] Signed: [Clinician name, credentials, date and time]
Use it for
Each one follows the template. Use them to judge how much detail every part needs.
Outpatient therapy practice, first session, in person, 75 minutes
Informed consent reviewed and signed. Limits of confidentiality explained: serious risk of harm to herself or others, suspected abuse of a child, and court orders. She asked whether her employer would be told; explained that nothing is shared without her written consent outside those exceptions. Agreed to the use of an AI scribe for the session.
38-year-old woman referred by her family physician. “I feel like I’m going through the motions.” Low mood most days for about 4 months, since her father’s stroke, after which she began helping with his care most evenings. Less interest in friends and running, early waking, low energy, poor concentration at work, and guilt about “not coping.” Took 1 week off work last month. Goals: “feel like myself again,” and run again.
Psychiatric: one episode of depression at 24, treated with therapy; no hospital stays, suicide attempts, or self-harm. Medical: hypothyroidism on levothyroxine; thyroid function last checked 1 year ago. No other medications; no known drug allergies. Substance use: 1 or 2 glasses of wine on weekends; no cannabis or other drugs; does not smoke. Trauma screen: asked in general terms about frightening or harmful experiences; she reported none.
Mother treated for depression. Lives with her partner and 2 children, ages 6 and 9. Works full time as an accountant. Her brother lives nearby but helps little with their father’s care. Has a close friend she confides in. Not religious. Strengths: organized, did well in therapy before, and motivated to change.
Passive thoughts in the past 2 weeks that “everyone would be better off without me”; no thoughts of acting on them, and no plan, intent, or preparation. No past attempts or self-harm. No firearms at home. No violence or safety concerns at home. Protective factors: her children, her partner, and wanting to get better. Formulation: passive ideation without plan or intent, with strong protective factors. Safety plan written together: warning signs, coping steps, people to contact, and to call 911 or go to the nearest emergency department if she feels unable to stay safe. Review it at each session.
Casually dressed, well groomed. Good eye contact; movements slowed. Speech soft and slow but coherent. Mood “empty”; affect constricted, tearful when talking about her father. Thought process logical; content of guilt and worry about caregiving; no delusions. No hallucinations. Alert and oriented; concentration mildly reduced. Insight and judgment good. PHQ-9 17. GAD-7 8.
Major depressive disorder, recurrent episode, moderate; caregiving strain is a main stressor. Thyroid contribution to be ruled out. Recommend weekly CBT with behavioral activation for 12 to 16 sessions. With her consent, a letter to her family physician asking for a thyroid recheck and a review of medication options. Information on caregiver support services. Initial goals: PHQ-9 below 10; running twice a week; share her father’s care with her brother. Next appointment in 1 week, in person.
University counseling center, first session, by video
Informed consent reviewed and signed electronically. Client at home, alone; location and an emergency contact confirmed. Limits of confidentiality explained. He asked whether his parents would be told; explained they would not without his consent, outside the exceptions. No recording used.
21-year-old man, self-referred after a friend raised concerns. Drinks 3 or 4 nights a week, often 8 or more drinks a night. Two blackouts in the past month, and a fall 3 weeks ago that needed stitches to his scalp. Missing morning classes; failed a midterm. Drinks more than he plans to, and needs more than before to feel the effect. “Everyone drinks like this, but I don’t like that I can’t remember nights.” Goals: cut down, and pass his courses.
Psychiatric: no past diagnoses or treatment; low mood for a day or two after heavy weekends. Medical: no conditions, medications, or allergies; seen in the emergency department for the scalp cut. Substance use: alcohol as above, since age 16; cannabis on some weekends; vapes nicotine daily; no other drugs. No morning drinking, shakes, or sweats on days without alcohol; no history of withdrawal seizures. Trauma screen: asked in general terms; reported none.
Father has alcohol use disorder and has been in recovery for 6 years. Second-year engineering student; lives with 3 roommates. Plays on a recreational soccer team. Close to his older sister. Student loans and a part-time job. Strengths: honest about his drinking, sees the harm, has friends who drink lightly, and has shown discipline in sport.
Denies suicidal ideation, now or in the past. No self-harm. No thoughts of harming others. Has not driven after drinking. Main safety risks are injury and alcohol poisoning when intoxicated. Protective factors: his sister, his team, and wanting to finish his degree. Formulation: low current risk of suicide; the risks are linked to intoxication. Discussed safer steps: eating before drinking, pacing, never drinking alone, and a friend to get home with. Friends should call 911 if he can’t be woken.
Casually dressed, well groomed, good eye contact. Speech normal. Mood “stressed”; affect anxious, full range. Thought process logical; content focused on grades and drinking. No hallucinations. Alert and oriented. Insight fair: sees the harm, unsure about change. Judgment fair. AUDIT 18. PHQ-9 7. GAD-7 6.
Alcohol use disorder, moderate: 4 criteria met, namely drinking more than intended, missed obligations, use despite low mood afterward, and tolerance. No signs of withdrawal. Low mood seems linked to drinking; reassess once he cuts down. Recommend weekly sessions using motivational interviewing and CBT for alcohol use. He chose to start with no drinking on weeknights and to track every drink. Suggested a check-up with a primary care clinician. Information on campus peer recovery support. Next appointment in 1 week by video.
What the client agreed to before you started, and a record that they understood when information may be shared without consent.
Avoid: A signed form with no conversation behind it. Explain the limits in plain words and note that the client understood.
Why the client is here now, in their words and the referrer’s.
Avoid: Recording only the referrer’s reason. The client’s view of the problem often differs, and it shapes the plan.
The background that explains the problem and affects treatment choices.
Avoid: Pressing for trauma details at a first session. Ask in general terms, and let the client decide what to share.
A structured look at suicide, self-harm, harm to others, and safety at home, with your judgment of what it means.
Avoid: A risk level with no reasoning. Write the facts behind your judgment, and what you did about them.
What you observed during the session, and the scores from any measures.
Avoid: “MSE within normal limits.” Record what you actually observed in each domain.
Your working diagnosis and the care you recommend, agreed with the client.
Avoid: A plan with no reasons. Link each recommendation to a problem or to one of the client’s goals.
When suicidal thoughts are present, ask about firearms, stored medications, and other means, and record what was agreed to make them safer.
Thyroid disease, medications, sleep problems, and substance use can cause or worsen mood and anxiety symptoms. Note what has been checked, and ask for a medical review when it hasn’t.
A PHQ-9 of 17 flags likely depression; it doesn’t make the diagnosis. Confirm the criteria in the interview, and record the features you found.
A referral letter is a starting point. Confirm the history with the client, and note where their account differs.
“Will continue to assess” leaves the next clinician guessing. Give a working impression, initial goals, and a next step, even if they change.
Vero Scribe writes the intake assessment in your template from the session, with the client’s consent, or from your dictation. You review and edit every section, then copy it into your record or export it to Word or PDF. Vero works in 60+ languages.
Most intakes take 60 to 90 minutes. If time runs short, cover risk, the presenting problem, and consent first, and finish the history at the next session.
Ask in general terms, explain why you’re asking, and let the client decide how much to share. A brief screen such as the PC-PTSD-5, or the PCL-5 when symptoms suggest PTSD, can guide what to explore later.
Explain in plain words when you may have to share information without consent where you practice, such as a serious risk of harm, suspected abuse of a child, or a court order. Record that you explained it and that the client understood.
Yes. Copy it, or download it as a Word or text file. No account needed.
One psychotherapy session: focus, interventions, client response, risk, and progress toward goals.
SOAP for therapy sessions, with mental status observations and PHQ-9 and GAD-7 scores.
Biological, psychological, social, and cultural factors, brought together in one formulation.
Problems, goals, measurable objectives, interventions, and review dates, agreed with the client.
One note per member: the group’s topic and interventions, then that member’s participation and plan.
Intake and progress notes, drafted for your review.
Bring visit goals, records, and preferences into one note.
Common codes for the diagnoses in your impression.
Notes, documents, and follow-up in one workspace.
Vero writes your notes and letters in the templates you choose, so you review instead of type.
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