Intake & Assessment

Intake & Assessment
Full Name
Date of Birth

MonthDayYear
Date
Gender/Pronouns
Address
Phone
Format: (000) 000-0000.
Email
example@example.com
Emergency Contact
Name
Relocation
Phone
Format: (000) 000-0000.
Insurance Information
Section 2 – Presenting Concerns
What brings you to counseling today?
How long have you been experiencing these concerns?
What do you hope to achieve in therapy?
Section 3 – Medical & Mental Health History
Current medical conditions
Current medications (dosage & provider)
Past hospitalizations (medical/psychiatric):
Family history of mental illness / substance use
Previous therapy or counseling experiences
Section 4 – Psychosocial Background
Living Situation
Relationships / family dynamics:
Employment / education status:
Cultural / spiritual background (optional)
Section 5 – Risk Assessment (Clinician Completes)
Homicidal ideation
Self-harm history:
Homicidal ideation:
Substance use concerns
Trauma History
Section 6 – Mental Status Exam (Clinician Completes)
Appearance / Behavior
Mood / Affect:
Speech:
Thought process/content
Orientation (time/place/person)
Insight / Judgment:
Section 7 – Clinical Impressions & Diagnosis (Clinician Completes)
Summary of findings
Provisional / confirmed DSM-5 diagnosis
Recommended level of care
Section 8 – Treatment Plan (Initial)
Short-term goals
Long-term goals
Frequency of sessions
Referrals (if needed)
Section 9 – Consent & Signatures
I consent to receive mental health treatment and acknowledge confidentiality policies (HIPAA
Client Signature
Date

MonthDayYear
Date
Clinician Signature
Date

MonthDayYear
Date
Should be Empty:

Intake & Assessment

Section 2 – Presenting Concerns

Section 3 – Medical & Mental Health History

Section 4 – Psychosocial Background

Section 5 – Risk Assessment (Clinician Completes)

Section 6 – Mental Status Exam (Clinician Completes)

Section 7 – Clinical Impressions & Diagnosis (Clinician Completes)

Section 8 – Treatment Plan (Initial)

Section 9 – Consent & Signatures