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How to Write a Psychiatric Intake Note: Guidelines, Template & Example

Dr. Medeline Yost

Chief Medical Officer, Augustun

Published July 2, 2026

Updated July 2, 2026

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Essential Sections of a Psychiatric Intake Note
Mental Status Exam: Document What You Observe
Example Psychiatric Intake Note
Intake Documentation Best Practices
FAQ

The psychiatric intake note is the foundation of mental health treatment. It captures who the patient is, why they are seeking care, what symptoms and risks are present, and what the initial treatment plan will be. Every follow-up note, medication adjustment, and crisis intervention builds on this first record.

Intake evaluations are longer and more structured than routine follow-up notes. They typically include identifying information, chief complaint, history of present illness (HPI), psychiatric and medical history, substance use history, family and social history, mental status examination (MSE), risk assessment, diagnostic impression, and treatment plan. Missing any of these sections can weaken medical necessity support and complicate care coordination.

This guide is focused specifically on the initial psychiatric evaluation — distinct from our broader overview of psychiatry notes and the follow-up-focused psychiatric SOAP note format. For a complementary assessment framework, see mental health assessment documentation.

Essential Sections of a Psychiatric Intake Note

Section	Purpose	What to include
Identifying information	Establish context	Age, gender, referral source, evaluation setting (outpatient, ED, telehealth), collateral sources.
Chief complaint	Patient's stated reason	In the patient's words when possible: "I can't sleep and I feel hopeless."
History of present illness	Symptom story	Onset, duration, severity, triggers, prior episodes, functional impact, prior treatments.
Psychiatric history	Past mental health care	Prior diagnoses, hospitalizations, suicide attempts, therapy, medication trials and responses.
Medical / substance / family / social history	Context and risk	Medical conditions, medications, allergies, substance use, trauma, supports, occupation, legal issues.
Mental status exam	Observable findings	Appearance, behavior, speech, mood/affect, thought process/content, perceptions, cognition, insight/judgment.
Risk assessment	Safety	Suicidal ideation, plan, intent, means; homicidal ideation; self-harm; grave disability; protective factors.
Assessment & plan	Clinical conclusions	Diagnoses (DSM/ICD), medical necessity rationale, labs if needed, medications, therapy, follow-up, crisis plan.

Mental Status Exam: Document What You Observe

The MSE is the objective core of a psychiatric intake. Unlike other specialties, psychiatry often has few lab markers at intake — the MSE and history carry the diagnostic weight. Document each domain systematically, even when findings are normal.

Appearance: grooming, attire, apparent age vs. stated age.
Behavior: eye contact, psychomotor activity, cooperativeness.
Speech: rate, volume, fluency, latency.
Mood / affect: patient's stated mood vs. observed affect (range, congruence).
Thought process: linear, tangential, circumstantial, disorganized.
Thought content: obsessions, delusions, preoccupations, SI/HI.
Perceptions: hallucinations, illusions — ask directly.
Cognition: orientation, attention, memory (as assessed).
Insight / judgment: awareness of illness, decision-making capacity for treatment.

Example Psychiatric Intake Note

Initial Psychiatric Evaluation — Adult Outpatient

Chief Complaint: "I have been depressed for months and I am not functioning at work."
History of Present Illness: 35-year-old patient reports 4-month history of depressed mood, anhedonia, insomnia with early-morning awakening, poor concentration, fatigue, and 12-lb unintentional weight loss. Symptoms began after job transition. Denies manic episodes. Prior episode at age 28 after divorce, treated with sertraline with partial benefit. PHQ-9 today: 19.
Psychiatric / Medical / Social History: No psychiatric hospitalizations or suicide attempts. No history of psychosis or substance use disorder. Medical history: hypothyroidism, on levothyroxine. Family history: mother with depression. Social: married, employed in finance, supportive spouse. No legal involvement. No allergies.
Mental Status Exam: Appearance: casually dressed, good hygiene. Behavior: cooperative, mild psychomotor slowing. Speech: soft volume, normal rate. Mood: "depressed"; affect: constricted, mood-congruent. Thought process: linear. Thought content: negative self-worth, no delusions, denies SI/HI. Perceptions: denies AVH. Cognition: alert, oriented x4. Insight: fair. Judgment: fair.
Risk Assessment: Denies current suicidal ideation, intent, plan, or preparatory behavior. Denies homicidal ideation. No evidence of grave disability requiring involuntary hold today. Protective factors: spouse support, help-seeking behavior, employed.
Assessment & Plan: Major depressive disorder, recurrent, moderate (F33.1). Initiate SSRI per shared decision-making; discussed risks, benefits, and timeline. Order TSH if not recent. Recommend weekly CBT-oriented therapy. Sleep hygiene and crisis resources reviewed. RTC 2 weeks for medication response and side effects. Patient to contact clinic or 988 if suicidal thoughts develop.

Intake Documentation Best Practices

Document informed consent for treatment and, when applicable, telehealth.
Record collateral information and who provided it.
Include rating scales (PHQ-9, GAD-7, AUDIT) at baseline for measurement-based care.
Be specific about prior medication trials: dose, duration, response, reason for discontinuation.
Separate facts from inference — especially for trauma and substance use history.
Close with a clear follow-up interval and crisis instructions.

Intake visits are documentation-heavy, which makes them a strong use case for an AI medical scribe. Augustun for psychiatry can draft structured intake notes from the evaluation conversation, organizing HPI, MSE, and risk sections for clinician review — saving time without skipping required elements.

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Augustun turns intake evaluations into structured, review-ready notes with specialty-aware templates. Explore [mental health assessment documentation](/blog/mental-health-assessment-documentation) for a complementary assessment framework.

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Frequently asked questions

How is a psychiatric intake note different from a SOAP note?

An intake note is a comprehensive initial evaluation with full history, MSE, and risk assessment. A SOAP note is a shorter structured format often used for follow-up visits. Many intakes use SOAP-like sections but are much longer and more detailed.

What rating scales should be included at psychiatric intake?

Common choices include PHQ-9 for depression, GAD-7 for anxiety, and condition-specific scales as appropriate. Baseline scores support measurement-based care and medical necessity documentation over time.

Must risk assessment be documented at every intake?

Yes. A documented risk assessment for suicidal and homicidal ideation, self-harm, and inability to care for self is standard of care at psychiatric intake — even when risk is low.