CBT Intake Assessment (Adult)

Date of Service: [Date]

Start/Stop Time: [Start time – Stop time] or [Total session time in minutes]

Modality: [in-person / video / phone]

Location/Site: [Clinic or location name]

Provider: [Name, credentials]

Participants: [Patient present alone / Patient present with other participants: name(s), relationship(s), consent status]; [Interpreter used: language, modality / No interpreter]

Information Sources: [Patient interview / collateral contacts / records reviewed / questionnaires completed]

Reliability: [Historian reliable / Limited by time or distress / Other qualifier]

(Throughout this note, distinguish between "denied" when asked and negative, "not assessed" when not asked, and "deferred" when intentionally postponed with reason and follow-up plan. Avoid ambiguous "N/A.")

Reason for Visit and Presenting Concerns

Chief Complaint: [Primary concern in 1–2 sentences; use patient's words in quotes when clinically meaningful]

[Narrative summary including: onset and course of symptoms, why seeking treatment now, symptom description with frequency and intensity and variability, precipitating stressors or context, functional impact on work and relationships and self-care and sleep, current coping strategies and their effectiveness, and patient's stated goals for CBT] (Write as a cohesive paragraph of approximately 6–12 sentences.)

Patient Strengths and Protective Factors:

• [Strength or protective factor]
• [Strength or protective factor]
• [Strength or protective factor]

(Include 2–5 factors such as social supports, values, responsibilities, prior coping successes.)

Symptom Review

(Document pertinent positives and negatives. For each domain, indicate present with brief description, denied, not assessed, or deferred with reason.)

• Mood symptoms: [Depressed mood, anhedonia, irritability, sleep changes, appetite or weight changes, energy, concentration, guilt or worthlessness, hopelessness]
• Anxiety symptoms: [Excessive worry, panic attacks, social anxiety, specific phobias, obsessions or compulsions, avoidance patterns, somatic anxiety]
• Trauma-related symptoms: [Trauma exposure at high level, intrusive symptoms, avoidance, hyperarousal, negative cognitions or mood, dissociation] (Screen at high level; avoid unnecessary graphic detail.)
• Psychosis and mania screening: [Hallucinations, delusions or paranoia, decreased need for sleep, pressured speech, grandiosity, increased goal-directed activity]
• Substance-related symptoms: [Current use patterns, cravings, loss of control, tolerance or withdrawal, consequences]
• Eating and body image symptoms: [Restriction, binge eating, purging, body image disturbance, compensatory behaviors] (Include only if clinically indicated.)
• Cognitive and attention symptoms: [Inattention, hyperactivity or impulsivity, memory concerns] (Include only if clinically indicated.)

History

Past Psychiatric History

• Prior diagnoses: [Patient-reported and record-confirmed diagnoses]
• Prior therapy: [Type, duration, response; what helped and what did not help]
• Psychiatric medications: [Prior trials with names, doses if known, response, side effects]
• Higher levels of care: [Hospitalizations, ED visits, intensive outpatient, partial hospitalization with approximate dates and reasons]
• Self-harm and suicide attempt history: [Brief high-level summary] (Detail current risk status in Risk and Safety Assessment section.)

Medical History

• Medical conditions: [Major diagnoses, surgeries, head injuries, chronic pain, sleep disorders]
• Current providers: [PCP, specialists, other treating clinicians]

Current Medications and Allergies

• Medications: [All current psychiatric and non-psychiatric medications with doses and adherence] (If none, state "No current medications reported.")
• Allergies: [Drug allergies and adverse reactions] (If none, state "No known drug allergies.")

Substance Use History

(For each relevant substance, document pattern, last use, consequences, treatment history, and safety concerns.)

• Alcohol: [Pattern and quantity, last use, consequences, treatment history, safety concerns]
• Cannabis: [Pattern, last use, consequences, treatment history]
• Nicotine: [Form and pattern, quit attempts, treatment]
• Stimulants: [Pattern, last use, consequences, treatment history, safety concerns]
• Opioids: [Pattern, last use, overdose history, treatment history, withdrawal risk]
• Sedatives: [Pattern, last use, consequences, treatment history, mixing concerns]
• Other substances: [Specify if applicable]

(Omit substances with no history. If patient denies all substance use, state "Patient denies current or past substance use.")

Trauma and Adverse Experiences

• Trauma history: [Types of trauma at non-graphic level with approximate timeframe]
• Treatment preferences: [Desire for trauma-focused treatment now or deferred] (If deferred, document reason and when it will be revisited.)

Family History

• [Psychiatric disorders in biological relatives]
• [Substance use disorders]
• [Suicide attempts or completions]
• [Violence history]

Social History

• Living situation: [Housing, safety, stability]
• Relationships: [Relationship status, caregiving responsibilities]
• Education and employment: [Level completed, current work status, occupational functioning]
• Social supports: [Support network, community connections]
• Legal: [Current legal stressors if any]
• Cultural factors: [Identity factors relevant to care and treatment preferences] (Include only when clinically relevant and patient-affirmed.)

Functional Assessment

• Work or school: [Performance, attendance, impairment]
• Relationships: [Family and social functioning]
• Sleep: [Routine, quality, duration]
• Self-care: [ADLs and IADLs]
• Physical health behaviors: [Activity level, nutrition]
• Pleasurable activities: [Engagement in valued or enjoyable activities]
• Avoidance patterns: [Situations, activities, or behaviors avoided; safety behaviors used]

Motivation for CBT: [Patient's readiness and engagement]

Practical Barriers: [Transportation, scheduling, finances, technology, or other barriers to treatment] (If none identified, state "No significant barriers identified.")

Baseline Measures

• [Depression measure]: [Score], [Severity band], [Date]
• [Anxiety measure]: [Score], [Severity band], [Date]
• [Suicide screening tool]: [Score or result], [Date]
• [Condition-specific measure]: [Score], [Severity band], [Date] (Include additional measures for PTSD, panic, insomnia, OCD, or other conditions as clinically indicated.)

[Clinical interpretation relating scores to reported symptoms and functional impairment; note any findings triggering additional assessment, higher level of care consideration, or medical referral] (If measures not completed, state "Measures not completed today; plan to administer at next visit." Do not estimate or fabricate scores.)

Mental Status Examination

Appearance and Behavior: [Grooming, attire, eye contact, psychomotor activity, cooperation]

Speech: [Rate, volume, prosody]

Mood: [Patient's stated mood in quotes]

Affect: [Range, intensity, congruence with mood, reactivity]

Thought Process: [linear and goal-directed / circumstantial / tangential / disorganized / other]

Thought Content: [Suicidal ideation, homicidal ideation, obsessions, ruminations, other notable content] (Detail in Risk and Safety Assessment section.)

Perception: [Hallucinations denied or described; dissociative symptoms if present]

Cognition: [Orientation, attention, memory] (grossly assessed)

Insight: [Understanding of illness and need for treatment]

Judgment: [Decision-making capacity, recent decisions]

CBT-Relevant Observations: [Cognitive patterns observed such as rumination, catastrophizing, black-and-white thinking; avoidance or safety behaviors demonstrated; emotion regulation patterns]

Risk and Safety Assessment

Suicide Risk

• Ideation: [none / passive wishes for death / active ideation] [frequency and duration if present]
• Plan: [none / vague / specific] [details if present]
• Intent: [none / ambivalent / present]
• Means access: [Firearms: present or absent, secured or unsecured] [Medications or other lethal means] [Means restriction counseling provided and patient response]
• Past attempts: [Number, approximate dates, methods, medical severity]
• Acute risk factors: [Current intoxication, recent loss, agitation, insomnia, hopelessness, command hallucinations, other acute factors]
• Protective factors: [Reasons for living, social supports, responsibilities, future orientation, treatment engagement]
• Overall suicide risk level: [low / moderate / high] with [brief clinical justification]

Violence Risk

• Ideation, plan, and intent: [Denied / describe if present]
• Weapons access: [Access status and counseling if indicated]
• History and triggers: [Prior violence, current triggers]
• Actions taken: [Duty to warn or protect actions if applicable]

Interpersonal Violence Screen

• [Current safety concerns regarding domestic or intimate partner violence] [Safety needs identified] [Mandatory reporting actions if applicable]

Safety Planning

• Safety plan: [Created / updated / not indicated] [Key elements if applicable]
• Crisis resources: [Resources provided per organization protocol]
• Patient agreement: [Patient's understanding and commitment to safety plan]

(If patient declines to answer risk questions, document refusal, counseling provided, and follow-up plan. If assessment abbreviated due to time constraints, document reason, interim safety steps taken, and plan to complete assessment.)

Diagnostic Impression

Working Diagnoses

• [ICD-10 code] [Diagnosis] [primary / secondary] [provisional if applicable]
  • [Key symptom supporting diagnosis]
  • [Additional supporting symptom or criterion]
  • [Functional impairment linked to diagnosis]
• [ICD-10 code] [Additional diagnosis] (Add additional diagnoses as clinically indicated.)

Differential Diagnosis

• [Condition considered]: [Supporting and refuting evidence; data needed to clarify]
• [Medical or substance-induced considerations]: [Relevant data and workup needed]

Clinical Formulation Summary

[Integrative paragraph summarizing primary presenting problems, key factors maintaining symptoms, relevant risk considerations, and rationale for CBT as appropriate treatment approach]

CBT Case Conceptualization

Problem List

(List 3–8 problems stated behaviorally and functionally, prioritized by safety first, then severity and patient priorities.)

• [Behaviorally stated problem with functional impact]
• [Behaviorally stated problem with functional impact]
• [Behaviorally stated problem with functional impact]

Cross-Sectional Formulation

(Document at least one recent typical episode illustrating the cognitive-behavioral cycle.)

• Situation or trigger: [Activating event or context]
• Automatic thoughts: [Patient's thoughts, quoted when possible]
• Emotions: [Emotional response with intensity rating if available]
• Physical sensations: [Bodily experiences]
• Behaviors: [Actions taken including avoidance and safety behaviors]
• Short-term relief versus long-term costs: [How behaviors provide immediate relief but maintain the problem]

Maintaining Mechanisms

(Identify mechanisms CBT will target; label as hypotheses unless directly evidenced.)

• [Avoidance cycles]
• [Safety behaviors or reassurance seeking]
• [Rumination or worry processes]
• [Behavioral withdrawal or reduced positive reinforcement]
• [Sleep disruption maintaining symptoms]
• [Interpersonal patterns]

Longitudinal Factors

(Include if relevant to initial treatment planning.)

• Predisposing vulnerabilities: [Developmental, temperamental, or historical factors]
• Core belief hypotheses: [Preliminary hypotheses clearly labeled as such]

Strengths Linked to Treatment

• [Patient strength or resource connected to planned intervention]
• [Support available for skill practice or exposure work]

Initial CBT Targets and Interventions

• [Target problem]: [Planned intervention] — [Brief rationale]
• [Target problem]: [Planned intervention] — [Brief rationale]

(Interventions may include psychoeducation, cognitive restructuring, behavioral experiments, exposure, behavioral activation, problem-solving, relaxation training, sleep hygiene, or other evidence-based CBT techniques.)

Initial Homework Assigned

• Assignment: [Specific task and frequency]
• Anticipated barriers: [Potential obstacles and solutions discussed]
• Collaboration: [Documentation that assignment was collaboratively developed with patient]

Treatment Plan

Modality and Frequency

[Individual CBT], [session frequency], [planned duration or review interval]

Treatment Goals

• Goal 1: [Measurable goal] — Baseline: [measure or indicator with value]; Target: [target value]; Timeframe: [expected duration]
• Goal 2: [Measurable goal] — Baseline: [measure or indicator with value]; Target: [target value]; Timeframe: [expected duration]

Coordination and Referrals

• Medical coordination: [PCP or psychiatry referral needs with rationale]
• Medication considerations: [Evaluation needs or current prescriber coordination]
• Releases of information: [ROIs obtained or needed]
• Level of care: [Higher level of care considerations if indicated]

Patient Education Provided

• [CBT rationale and treatment model]
• [Session structure and role of between-session practice]
• [Confidentiality and its limits]
• [Treatment alternatives discussed]

Follow-Up

Next appointment: [Date and time or scheduling plan]

Planned for next session: [Deferred assessments, measures to administer, topics to address]

Consent and Administrative

[Documentation that informed consent for treatment was obtained, including discussion of confidentiality limits such as mandated reporting, duty to protect, and emergency situations]

Provider Signature: [Electronic signature with credentials, date, and time]

(For any corrections after signing, add a clearly labeled addendum with date, time, and rationale. Do not alter original content.)