Intake Assessment Template
for Clinicians
Last updated: March 2026
Reviewed by the WellNotes Clinical Team
Type or dictate your initial evaluation observations. Get a thorough intake assessment — presenting problem, history, mental status, diagnosis, and recommendations — in minutes.
What is a Intake Assessment?
The intake assessment is the most comprehensive clinical document in a client's chart. Completed during the initial evaluation, it captures a detailed picture of the client's presenting problems, psychosocial history, mental status, and treatment needs. A thorough intake assessment forms the foundation for diagnosis, treatment planning, and ongoing clinical decision-making.
Intake assessments serve multiple critical functions: they establish medical necessity for treatment, provide a baseline for measuring progress, identify risk factors and safety concerns, and create a complete clinical picture that any treating provider can reference. Insurance companies and licensing boards expect detailed intake documentation that supports diagnostic conclusions.
For clinicians seeing multiple new clients each week, intake documentation can consume hours of administrative time. WellNotes streamlines this process by generating comprehensive intake reports from your session observations — maintaining clinical rigor while dramatically reducing documentation burden.
How It Works
Three steps to a finished intake assessment
Describe the Evaluation
Type or dictate your observations from the intake session — presenting concerns, history, mental status findings. No special formatting needed.
WellNotes Builds Your Assessment
Your observations are expanded into a comprehensive intake report with presenting problem, history, mental status exam, diagnostic impressions, and treatment recommendations.
Review, Edit, and Sign
Read through the assessment, refine any details, then export as PDF or copy to your EHR. Done.
Intake Assessment Sections Explained
Presenting Problem
The primary concerns that brought the client to treatment — symptoms, duration, severity, and functional impact as described by the client and observed by the clinician.
History
Relevant background information — psychiatric history, medical history, family history, social history, substance use history, and developmental history.
Mental Status
A structured assessment of the client's current mental functioning — appearance, behavior, speech, mood, affect, thought process, thought content, cognition, insight, and judgment.
Diagnosis
Clinical diagnostic impressions based on DSM-5 criteria — primary and secondary diagnoses with supporting evidence.
Treatment Recommendations
Recommended treatment approach — modality, frequency, initial goals, and any referrals or additional assessments needed.
Documentation Before & After WellNotes
You just finished a 90-minute intake evaluation. Your head is full of clinical observations, history details, and diagnostic impressions. Now you need to organize it all into a comprehensive report. An hour later, you're still writing.
Evaluation ends. You dictate your key observations. A complete intake assessment appears — history, mental status, diagnosis, and recommendations — ready to refine and sign.
Intake Assessment Example
A realistic sample generated by WellNotes
Presenting Problem
Client is a 28-year-old male self-referred for therapy due to "panic attacks that are ruining my life." Reports experiencing 3-4 panic attacks per week for the past 3 months, characterized by rapid heartbeat, shortness of breath, dizziness, and fear of dying. Onset coincided with a promotion to management role. Reports significant avoidance of meetings, public speaking, and driving on highways. Panic symptoms have led to 4 missed work days in the past month. Reports relationship strain with partner due to cancelled social plans.
History
Psychiatric: No prior therapy or psychiatric treatment. Reports "always being a worrier" since adolescence. Denies prior panic attacks before 3 months ago. Medical: No significant medical history. No current medications. Allergies: NKDA. Family: Mother has diagnosed Generalized Anxiety Disorder, treated with medication. Father has history of alcohol use disorder (in recovery 10 years). One younger sister, no reported mental health concerns. Social: Lives with partner of 3 years. College-educated, works as project manager at tech company. Reports supportive friend group but has been withdrawing recently. Substance use: Social alcohol use (2-3 drinks/week), denies cannabis or other substance use. Denies tobacco. Developmental: Reports normal developmental milestones. No reported trauma or abuse.
Mental Status
Appearance: Well-groomed male appearing stated age, dressed in business casual attire. Behavior: Cooperative and engaged, mild psychomotor agitation (fidgeting with hands). Eye contact: Good but intermittent. Speech: Normal rate, slightly pressured when discussing panic symptoms. Mood: "Anxious and frustrated." Affect: Anxious, congruent with mood, appropriate range. Thought process: Linear and goal-directed with tendency toward catastrophic thinking. Thought content: Preoccupied with panic symptoms and fear of future attacks. Denies SI/HI. Denies auditory/visual hallucinations. No delusions noted. Cognition: Alert and oriented x4. Memory and concentration intact. Insight: Good — recognizes anxiety as excessive. Judgment: Good — sought treatment independently.
Diagnosis
1. Panic Disorder (F41.0) — meets DSM-5 criteria: recurrent unexpected panic attacks with persistent concern about additional attacks and maladaptive behavioral changes (avoidance) for > 1 month. 2. Agoraphobia (F40.00) — avoidance of situations where escape may be difficult (highway driving, crowded meetings) due to fear of panic symptoms. Rule out: Generalized Anxiety Disorder — pre-existing worry pattern warrants monitoring.
Treatment Recommendations
1. Individual psychotherapy: CBT with panic-focused protocol, weekly 50-minute sessions for initial 12 weeks. 2. Interoceptive exposure exercises to reduce fear of physical sensations. 3. Graduated in-vivo exposure for agoraphobic avoidance. 4. Psychoeducation on panic cycle and fight-or-flight response. 5. Consider psychiatric referral for medication evaluation if insufficient response to CBT alone within 6-8 weeks. 6. Treatment plan to be developed collaboratively by session 2. 7. Reassess symptoms with standardized measures (PDSS, GAD-7) every 4 weeks.
Who Uses Intake Assessment?
Frequently Asked Questions
What should an intake assessment include?+
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Learn moreStart Writing Intake Assessment in Minutes
Built for clinicians, by clinicians. Type brief session observations. Get a complete, secure intake assessment — structured, formatted, and ready to save.
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