THERAPY 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]