Intake Assessment (Dance/Movement Therapy)

Note Type: Intake Assessment (Dance/Movement Therapy)

Client Name: [Client name]

DOB or MRN: [Date of birth or MRN]

Date of Service: [Date]

Start/Stop Time: [Start time – Stop time] (Include only when required by payer)

Location/Setting: [Setting]

Modality: [individual / group]; [in-person / telehealth]

Referral Source: [Name, agency, or self-referral] (Document "Unknown" if not available)

Reason for Referral: [Reason or clinical questions to be addressed] (Document "Unknown" if not available)

Guardian/Legal Decision-Maker: [Name and relationship] (Include for minors or adults with guardianship; omit if not applicable)

Consent and Confidentiality

• Consent for DMT assessment and treatment: [obtained / reviewed / declined / deferred]. [Details or limitations] (If declined or deferred, document reason and alternative action taken)
• Confidentiality and limits including mandated reporting: [reviewed / declined]. [Client understanding or questions]
• Touch practices and physical boundaries: [discussed / consent obtained / declined]. [Client preferences and boundaries] (Include only if touch may be part of treatment)
• Use of photos, video, or movement recordings: [permission granted / permission denied / not applicable]. [Purpose, storage location, access, and retention] (Include only if recordings will be used)
• Other consents: [Releases of information, telehealth consent, or other relevant consents] (Include only if applicable)

Presenting Concerns and Client Goals

Chief Concern: [One-line chief concern]

[History of present illness narrative covering primary concerns, functional impact on work/relationships/daily activities/somatic distress, onset, duration, course, and triggers]

• Client quotes: "[Direct quote]" (Include 1–2 quotes only when they materially clarify concerns or goals)
• Client goals: [Stated goals and preferences] (If client cannot articulate goals, note this and indicate plan to revisit)
• Comfort with movement-based exploration: [comfortable / ambivalent / uncomfortable]. [Preferences, pacing, or accommodations]

Relevant History

(Document pertinent history in concise bullets. If any area was not assessed, document the reason rather than using default language like "denies.")

• Psychiatric and behavioral health: [Prior diagnoses, treatments and response, hospitalizations, prior risk events]
• Trauma and adverse experiences: [Relevant experiences and current safety considerations] (Document minimally)
• Medical history relevant to movement: [Mobility, balance, pain, seizures, cardiovascular limitations, medications affecting movement or alertness, recent injuries or surgeries]
• Substance use: [Substances, pattern, impact on functioning] (Include if clinically indicated)
• Developmental history: [Developmental milestones, neurodevelopmental considerations] (Include when applicable)
• Family mental health and medical history: [Pertinent family factors]
• Social history: [Living situation, supports, education/work, cultural and spiritual factors, identity factors relevant to care]
• Strengths and resilience: [Prior coping strategies, meaningful activities, relationship with movement and the body]
• Areas not assessed: [Domain and reason] (Include if applicable)

Mental Status and Behavioral Observations

(Document observable clinical data. Clearly label any interpretive statements.)

• Appearance: [Appearance and grooming]
• Behavior and engagement: [Participation, responsiveness to cues, ability to reflect on experience]
• Psychomotor: [slowed / normal / increased]. [Restlessness, tics, tremor, or gait observations]
• Orientation and attention: [Orientation to person, place, time, situation]. [Attention and concentration]
• Speech: [Rate, volume, prosody, articulation]
• Mood and affect: [Stated mood]. [Affect range, stability, and congruence]
• Thought process: [coherent / logical / goal-directed / circumstantial / tangential / disorganized]
• Thought content: [Suicidal ideation, homicidal ideation, hallucinations, delusions, obsessions] (Document if assessed)
• Perception: [Hallucinations, illusions, dissociation indicators]
• Insight and judgment: [intact / fair / limited]. [Brief examples if observed]

Movement Assessment

Context: [Setting constraints, how movement was elicited (spontaneous / guided warm-up / mirroring / rhythm work / grounding / improvisation), client choice points about participation, and any adaptations]

• Body organization and actions: [Posture, alignment, coordination, breath, gestures, expressive range]
• Effort and energy dynamics: [Intensity, speed, sustained vs. sudden qualities, flow (bound/free)]
• Shape and spatial patterns: [Expanding/contracting, use of space, proximity, boundaries, directionality]
• Rhythm and phrasing: [Tempo, variability, pauses, transitions, ability to start and stop]
• Relational and interactive movement: [Mirroring, attunement, leading/following, contact preferences, eye gaze, timing]
• Safety-relevant somatic observations: [Pain behaviors, fatigue, dizziness, dissociation indicators, fall risk] (Include if observed)
• Client subjective report: [Sensations, emotions, images or associations during movement, meaning attributed to movement, stillness, touch, or space, cultural or personal considerations]
• Divergence between observation and report: [Description without judgment] (Include if present)
• Clinical hypotheses (labeled as hypotheses): [Movement-informed hypotheses linking observations to regulation, affect tolerance, or relational patterns] (Tie to observed data; avoid definitive etiological conclusions)
• Assessment limitations: [Telehealth constraints, client declined, medical limitations, alternative data sources used] (Include if applicable)

Strengths and Protective Factors

• Individual strengths: [Coping skills, values, interests, motivation, readiness for change]
• Social supports: [Key relationships, community connection, caregivers]
• Cultural and spiritual resources: [Traditions, beliefs, practices, community resources]
• Practical factors: [Housing stability, employment/education, transportation, access to care]
• Embodied strengths: [Self-regulation via breath or movement, ability to track sensations, rhythmic stability, creative expression capacity, movement repertoire]

Risk Assessment

(Document risk screening explicitly even when findings are negative. Do not leave blank.)

• Suicide and self-harm: [Ideation (current/past), plan, intent, behaviors, access to means]
• Violence risk: [Ideation, targets, access to weapons, escalating conflicts]
• Abuse, neglect, and mandated reporting: [Concerns present / absent]. [Report filed / consultation sought / not indicated]
• Grave disability or self-care impairment: [Nutrition, housing, medical adherence, safety concerns]
• Protective factors: [Reference relevant factors from Strengths section]
• Overall risk level: [low / moderate / high]. [Brief rationale]
• Safety planning: [Means restriction, coping strategies, warning signs, support contacts, crisis resources provided] (Include if any risk identified; if no safety plan created, document reason)

Clinical Formulation and Diagnostic Impression

[Integrative formulation summarizing presenting problem, key maintaining factors, functional impairment, and movement-informed hypotheses about regulation, affect tolerance, or relational patterns]

• Diagnostic impressions: [DSM/ICD codes] [provisional / rule-out / deferred] (Include only if within scope and supported)
• Symptom-focused clinical impression: [Brief description] (Use if diagnosis not established or outside scope)

Treatment Plan

• Level of care and format: [outpatient / intensive outpatient / other]. [individual / group]. [in-person / telehealth]. [Frequency and duration]
• Coordination with other services: [Providers or teams involved, releases of information obtained or needed]
• Initial treatment goals:
  • Goal 1: [Behavioral, functional, or regulation-focused goal]. Approach: [DMT intervention]. Measurement: [Tracking plan]
  • Goal 2: [Goal]. Approach: [Intervention]. Measurement: [Tracking plan]
  • Goal 3: [Goal]. Approach: [Intervention]. Measurement: [Tracking plan] (Include 2–5 goals total)
• Client preferences and shared decision-making: [Preferences, pacing, cultural considerations, accommodations]
• If treatment cannot begin: [Recommendations, referral or handoff plan] (Include if applicable)

Referrals and Follow-Up

• Referrals placed or recommended: [Service type and reason]
• Releases of information: [Organizations or individuals]. [obtained / pending / declined]
• Next appointment: [Date, time, format]
• Contingency plan: [Instructions and contacts if risk factors present] (Include if applicable)

Signature

[Provider name, credentials]

[Electronic signature], [Date and time]

(This note is part of the clinical record per organizational policy.)