Intake Assessment (Drama Therapy)

Note Type: Intake Assessment (Drama Therapy) | Date of Service: [Date] | Start Time: [Start time] | End Time: [End time]

Location/Setting: [Location/Setting] | Modality: [in-person / telehealth]

Clinician: [Clinician name, credentials, role] | Client: [Client name], DOB: [DOB], MRN: [MRN]

Referral Source: [Referral source] | Collateral Present: [Names and roles, or "None"]

Consent Status: [Informed consent obtained / not obtained]; [Releases of information status]; [Limits of confidentiality reviewed / not reviewed]

Presenting Concerns

Chief Concern: [Reason for seeking drama therapy; brief client quote if relevant; clinician summary] (If referral-driven, include both referral question and client's stated goals)

Presenting Problem: [Onset and timeline; triggers or precipitants; current symptoms by domain as relevant; severity and functional impact; modifiers; client goals and hoped-for outcomes; prior attempts to address the problem]

Client Preferences and Access Needs: [Communication needs; accessibility needs; cultural or spiritual considerations; safety considerations for experiential work; medical limitations relevant to movement, voice, or breath] (Include only when relevant; omit section if none identified)

Relevant History

Mental Health History:

• [Prior diagnoses]
• [Prior treatments and response; hospitalizations or crises]
• [Current and past psychiatric medications] (Include only if within scope)

Trauma and Adverse Experiences: [Brief description of trauma exposure if clinically indicated; current trauma-related symptoms; triggers relevant to drama or embodiment work] (If client declines to discuss, document declination; omit section if not clinically indicated)

Substance Use: [Substances used; frequency; last use; functional impact; withdrawal or intoxication concerns] (Include only if clinically indicated)

Medical and Developmental History: [Medical conditions affecting movement, voice, or breath; pain; seizures or fainting; pregnancy status if relevant; medications affecting arousal; for youth: developmental milestones and school supports]

Family and Social History: [Household and relationships; social supports and community belonging; isolation concerns; relevant family mental health or substance history]

Strengths, Interests, and Resources: [Coping skills; creative interests; prior theatre or drama exposure; play preferences; values; cultural and community strengths; spiritual resources]

Functional Status

• ADLs/IADLs: [Hygiene; eating; sleep routine; appointment management]
• Work/School: [Attendance; performance; accommodations]
• Interpersonal Functioning: [Conflict; withdrawal; social anxiety]
• Emotional Regulation: [Anger; shutdown; dissociation episodes]
• Risk-Related Functioning: [Impulse control; supervision needs for youth] (Include if relevant)

Mental Status Examination

• Appearance/Behavior: [Appearance; posture; motor activity; eye contact; cooperation]
• Speech: [Rate; volume; articulation; fluency]
• Mood (reported): [Client-reported mood] | Affect (observed): [Range; congruence; stability]
• Thought Process: [Linear / tangential / circumstantial / disorganized]
• Thought Content: [SI/HI present or denied; delusions; obsessions]
• Perception: [Hallucinations or perceptual disturbances, or "No perceptual disturbances reported"]
• Cognition: [Orientation; attention; memory] (Expand testing only if clinically indicated)
• Insight/Judgment: [Insight level; decision-making capacity]
• Reliability: [Factors impacting reliability of presentation] (Include only if applicable)

Risk and Safety Screening

(Required for all intakes. If screening was not completed, document reason and mitigation plan.)

Suicide and Self-Harm Risk:

• Screening: [Tool used and result, if applicable]
• Current Ideation: [Present / denied]; [Frequency if present]
• Plan/Intent/Preparatory Behaviors: [Findings]
• History: [Prior attempts or self-harm with brief timeline]
• Means Access: [Access to lethal means; means restriction counseling provided if applicable]
• Risk and Protective Factors: [Key factors identified]
• Risk Level: [Low / moderate / high] — [Rationale]
• Mitigation Plan: [Safety planning actions; crisis resources provided; follow-up timing]

Violence Risk: [Ideation; intent; plan; access to weapons; history of violence; duty-to-warn actions if taken] (Include only when indicated)

Abuse and Neglect: [Screening findings; mandated reporting actions and timing] (Include for minors or vulnerable adults if applicable)

Drama Therapy Assessment

Prior Drama and Play Experience: [Prior theatre or drama experience and valence; comfort with imagination, play, improvisation, storytelling; performance anxiety or shame concerns; preference for structured vs. open-ended activities; preference for verbal vs. nonverbal expression]

Capacity for Dramatic Reality and Distancing: [Ability to differentiate role or story from self; over-identification vs. over-detachment tendencies; response to metaphor, fiction, or projective distance]

Embodiment Tolerance: [Comfort with movement, breath, voice, and posture work; dissociation risk with interoception or movement; triggers involving body; physical limitations; consent and boundary considerations for embodied work]

Role Repertoire: [Common roles occupied; desired or underdeveloped roles; role rigidity vs. flexibility; capacity for role reversal; manifestation of roles in relationships]

Projective Media Preferences: [Preferred or safe media; literacy and language considerations for narrative work; cultural considerations regarding symbols or themes]

Group Readiness: [Motivation for group vs. individual; boundary and confidentiality capacity; tolerance for witnessing emotions and being seen; behavioral stability; practical readiness] (Include only if group therapy is being considered)

Contraindications and Titration Plan: [Methods to avoid initially and rationale; pacing plan; supports needed]

Clinical Formulation

• Predisposing Factors: [Relevant vulnerabilities or history]
• Precipitating Factors: [Recent triggers or stressors]
• Perpetuating Factors: [Maintaining factors including behavioral, interpersonal, and environmental contributors]
• Protective Factors: [Strengths, supports, values, coping skills]

Why Drama Therapy Now: [Rationale linking presentation to drama therapy indication; mechanism of change hypothesis]

Level of Care Rationale: [Why outpatient drama therapy is appropriate; referrals if higher level of care indicated]

Diagnosis and Problem List

• [Diagnosis 1]: [Working / provisional]; [Key supporting symptoms]; [Functional impairment]; [Risk considerations] (Repeat for additional diagnoses as applicable)
• Rule-outs: [Conditions to clarify and plan to refine diagnosis] (Include if diagnostic certainty is limited)
• Psychosocial/Contextual Problems: [Relevant stressors or context impacting care] (Include if applicable)

Recommendations and Plan

Treatment Recommendations: [Recommended service type: individual drama therapy / group drama therapy / adjunctive psychotherapy / psychiatry referral]; [Frequency]; [Expected initial duration]; [Coordination of care: releases requested, providers to contact]

Initial Goals:

• [Goal 1 with measurable behavioral indicators]
• [Goal 2 with measurable behavioral indicators]
• [Additional goals as needed] (2–4 goals total)

Planned Drama Therapy Interventions: [Selected methods and brief rationale aligned to assessment findings]

Safety Plan: [Actions taken; resources provided; means restriction counseling; follow-up timing] (Include only if risk screening indicated elevated risk)

Follow-Up: [Next appointment date or scheduling plan]; [Referrals placed and urgency]; [Criteria for stepping up care]

Signature

Clinician Signature: [Clinician name], [Credentials] — [Date signed] (If late entry or amendment, note date, time, and reason)