Clinical Template

Intake Assessment Template and Examples

Last updated: October 6, 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 an Intake Assessment template?

An intake assessment template documents the first session: the presenting problem, relevant history (psychiatric, medical, substance use, family and social), a mental status exam, risk assessment, diagnostic impressions and treatment recommendations. A complete intake gives you the medical necessity basis for the treatment plan and the first point to measure progress against.

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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.

Intake Assessment Template Structure

Use these 5 headings, in this order, for every intake assessment. Each card explains what belongs in the section.

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.

Intake Assessment Examples

3 filled examples for different sessions, written in the template above.

All examples are fictional and de-identified. They show structure and level of detail, not clinical advice for a real client.

Intake Assessment Example 1: Panic attacks (adult self-referral)

Adult client self-referred for panic attacks starting three months ago.

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.

Intake Assessment Example 2: Depression (adult, referred by primary care)

Adult client referred by a primary care provider after a positive depression screen.

Presenting Problem: Client referred by primary care after a PHQ-9 of 18. Reports low mood, loss of interest in hobbies, fatigue and poor concentration for about 4 months, starting after a divorce was finalized. Has reduced work hours. States "I just go through the motions."
History: Psychiatric: one prior episode of depression in her 20s treated with therapy. No hospitalizations. Medical: hypothyroidism, treated. Substance use: 1 to 2 glasses of wine on weekends, denies other substances. Family: mother with depression. Social: lives alone, two adult children nearby, employed as an accountant.
Mental Status: Appearance appropriate. Cooperative, fair eye contact. Speech slow, low volume. Mood "flat." Affect constricted. Thought process linear, no psychotic features. Cognition grossly intact. Insight and judgment good. Risk: endorses passive thoughts of "not waking up" in the past month, denies plan, intent or past attempts; denies HI. Firearms: none in the home.
Diagnosis: Major depressive disorder, recurrent, moderate (provisional pending review of medical records). Rule out depressive symptoms related to thyroid function; client reports recent normal labs.
Treatment Recommendations: 1. Weekly individual therapy using CBT and behavioral activation. 2. Safety plan completed today; reassess risk each session. 3. With consent, coordinate with primary care regarding medication evaluation. 4. PHQ-9 every 2 weeks. 5. Develop treatment plan at session 2.

Intake Assessment Example 3: Adolescent referral (school concerns)

14-year-old client brought by a caregiver after a drop in grades.

Presenting Problem: Caregiver reports client's grades fell from mostly Bs to Ds and Fs over the semester, with increased time alone in her room and irritability. Client says school is "pointless" and reports trouble sleeping. Seen with caregiver for the first part of the session and alone for the second.
History: Psychiatric: no prior treatment. Medical: asthma, well controlled. Developmental: milestones on time per caregiver. Substance use: client reports trying vaping twice; denies alcohol or other drugs. Family: parents separated last year, lives with mother and younger brother. Social: reports losing a close friend group this year.
Mental Status: Casually dressed, appropriately groomed. Guarded with caregiver present, more open alone. Mood "bored." Affect irritable, then tearful. Thought process linear. No perceptual disturbances. Risk: denies SI, self-harm and HI when interviewed alone; caregiver unaware of any concerns.
Diagnosis: Provisional: adjustment disorder with mixed anxiety and depressed mood. Will gather school and rating scale data to clarify.
Treatment Recommendations: 1. Weekly individual therapy with periodic caregiver sessions. 2. Administer adolescent depression and anxiety rating scales at session 2. 3. With consent, request a release to speak with the school counselor. 4. Provide caregiver with crisis resources. 5. Treatment plan at session 2 or 3.

Therapy intake questions to ask

Use these as prompts, not a script. Let the client tell their story first, then fill gaps. Adapt the wording for children, caregivers and couples.

Reason for seeking help: What brings you in now? When did this start? What have you already tried? What would you like to be different after therapy?
Symptoms and functioning: How are you sleeping and eating? How is your energy and concentration? How is this affecting work, school, home or relationships?
Mental health history: Have you had counseling, medication or a hospital stay for mental health before? What helped and what did not?
Medical history: Do you have any health conditions? What medications do you take, and who prescribes them? When did you last see a primary care provider?
Substance use: How often do you drink alcohol, and how much? Do you use cannabis, tobacco or other substances? Has anyone been concerned about your use?
Family: Who is in your family and who do you live with? Has anyone in your family had mental health or substance use problems?
Social and practical: What do you do for work or school? Is your housing stable? Who do you turn to for support? Is there anything legal or financial that is weighing on you?
Trauma and safety at home: Have you experienced events that still affect you? Do you feel safe at home? (Let the client decide how much detail to share at intake.)
Risk: Have you had thoughts that life is not worth living, or thoughts of killing yourself? Have you ever tried to harm yourself? Have you had thoughts of harming anyone else? Do you have access to firearms?
Strengths and culture: What are you good at, or proud of? What gives you hope? Is there anything about your culture, identity or beliefs you want me to understand?

For a fuller history format that adds a formulation, see the biopsychosocial assessment template.

Mental status exam at intake

The Mental Status section of an intake summarizes how the client presented: appearance, behavior, speech, mood, affect, thought process and content, perception, cognition, insight and judgment, plus the risk questions asked. Keep it descriptive and complete. For every domain with prompts, the terms to describe affect and thought process, and two full examples, use the mental status exam template.

How to Write an Intake Assessment

Presenting problem. Describe why the client is seeking care now, in their words, with onset, duration, severity and impact on functioning.
History. Cover psychiatric, medical, substance use, family, social, developmental (for children), trauma and legal history as relevant to the presenting problem.
Mental status and risk. Summarize the mental status exam and record a structured risk screen with the questions asked and the answers.
Diagnosis. Give diagnostic impressions with the supporting criteria, and mark provisional diagnoses as provisional.
Recommendations. List the recommended level of care, modality, frequency, referrals, measures and next steps toward a treatment plan.

Common Intake Assessment Mistakes

Skipping a structured risk assessment at intake.
Diagnoses with no supporting symptoms documented elsewhere in the intake.
Not noting who provided the information (client, caregiver, records).
Recommendations that are too general to build a treatment plan from.

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, and 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.

Documentation Before & After WellNotes

Before 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.

After WellNotes

Evaluation ends. You dictate your key observations. A complete intake assessment appears with history, mental status, diagnosis, and recommendations, ready to refine and sign.

From 60+ minutes to under 10

Who Uses Intake Assessment?

TherapistsPsychologistsCounselorsSocial WorkersPsychiatrists

Intake Assessment FAQ

What is an example of an intake assessment?

A short example: Presenting problem, four months of low mood and fatigue after a divorce; History, one prior episode, no substance misuse; Mental status, constricted affect, passive death wishes without plan or intent; Diagnosis, major depressive disorder, recurrent, moderate; Recommendations, weekly CBT, safety plan and coordination with primary care.

What should an intake assessment include?

A thorough intake assessment should include the presenting problem (symptoms, duration, severity), relevant history (psychiatric, medical, family, social, substance use), a mental status examination, diagnostic impressions based on DSM-5 criteria, and treatment recommendations. WellNotes generates all five sections from your clinical observations.

Is an intake assessment required for insurance?

Yes. Insurance companies require intake documentation that establishes medical necessity before authorizing ongoing treatment. The intake assessment provides the diagnostic foundation and clinical justification for the treatment plan. Incomplete intake documentation is one of the most common reasons for claim denials.

What is the difference between an intake assessment and a progress note?

An intake assessment is a comprehensive initial evaluation completed at the start of treatment. It captures the full clinical picture including history, diagnosis, and treatment recommendations. Progress notes (like SOAP, DAP, or BIRP) document individual sessions after the intake and track ongoing treatment progress.

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