Intake Assessment (Psychotherapy)

Date of Service: [Date]

Patient Name: [Full name]

Date of Birth: [DOB]

Clinician: [Name, credentials]

Location/Setting: [Location or setting]

Participants: [List who was present and their roles]

Sources: [List all sources used: patient report, collateral, prior records, referral documentation, rating scales]

Reliability: [Factors limiting reliability] (Include only if history limited by intoxication, guardedness, cognitive impairment, or language barrier; otherwise omit this field.)

Referral Source: [Referral source and reason] (Include if applicable.)

Consent: [Consent documentation] (Note consent for treatment obtained. For minors, include guardian consent, youth assent, and confidentiality boundaries explained.)

Chief Complaint

[Primary concern in patient's own words when meaningful; include referrer-stated reason if applicable]

Patient Goals

• [Goal 1: what success looks like to the patient]
• [Goal 2: additional goal or therapy preferences if stated]
• [Goal 3] (Include only if clearly stated.)

History of Present Illness

[Narrative summary of presenting problem] (Begin with chief concern. Include onset and duration, course, precipitating events, symptom frequency and intensity, functional impact on work/school/relationships/self-care, triggers and maintaining factors, coping strategies used, current stressors and supports. Note any safety signals such as hopelessness, burdensomeness, escalating substance use, or access to lethal means.)

Symptom Review

• Depression: [endorsed / denied / not assessed] (If endorsed, summarize key symptoms and severity. Include screener scores with interpretation when used.)
• Anxiety: [endorsed / denied / not assessed] (Differentiate generalized, panic, social, OCD features if present.)
• Trauma-related: [endorsed / denied / not assessed] (Note re-experiencing, avoidance, hyperarousal, dissociation if present.)
• Psychosis spectrum: [endorsed / denied / not assessed] (Note hallucinations, delusions, thought disorder if present.)
• Bipolar/mania screen: [endorsed / denied / not assessed] (Note elevated mood, decreased sleep need, increased goal-directed activity, impulsivity.)
• Eating/body image: [endorsed / denied / not assessed] (Summarize intake concerns, weight/shape preoccupation, compensatory behaviors.)
• Sleep: [endorsed / denied / not assessed] (Insomnia, hypersomnia, sleep quality, nightmares.)
• Substance use: [endorsed / denied / not assessed] (Summarize substances, quantity/frequency, consequences, stage of change, harm-reduction steps discussed.)
• Other relevant symptoms: [Specify] (Omit if not clinically relevant.)

Past Psychiatric History

• Prior diagnoses: [Patient-reported and chart-documented diagnoses]
• Psychotherapy: [Types, duration, response]
• Psychiatric medications: [Medications tried, approximate doses, response, adverse effects]
• Hospitalizations/ED visits: [Number, timing, reasons]
• Suicide attempts: [Method, medical lethality, recency; include aborted or interrupted attempts]
• Non-suicidal self-injury: [Behaviors, frequency, recency]
• Violence/aggression history: [Summary] (Include if relevant to risk.)
• Psychological testing: [Prior results] (Include if available.)

Medical History

• Major medical conditions: [Conditions relevant to mental health]
• Current medications and supplements: [Medications relevant to psychiatric care]
• Allergies: [Medication and relevant allergies]
• Developmental history: [Milestones, learning issues, IEP/504] (Include only for children/adolescents or when ADHD, ASD, intellectual disability, or TBI concerns are relevant; otherwise omit.)

Family Psychiatric History

[Relevant psychiatric history in first-degree relatives] (Note mood disorders, psychosis, substance use disorders, suicide attempts or deaths, neurodevelopmental disorders. Keep concise.)

Social History

• Living situation: [Where and with whom patient lives]
• Relationships/supports: [Partner status, key social supports]
• Education/employment: [Highest education, current role, notable stressors]
• Financial/housing stressors: [Summary] (Include if relevant.)
• Legal history: [Summary] (Include only if clinically relevant.)
• Military service: [Branch, dates, combat exposure] (Include if applicable.)
• Cultural/identity factors: [Factors affecting care and engagement]
• Religion/spirituality: [Role in coping or care] (Include if relevant.)
• Strengths and protective factors: [Hobbies, values, community connections, coping skills]
• Access to lethal means: [Firearms or other means in home; storage practices]

Trauma History

• Screening domains: [Childhood adversity / sexual assault / domestic violence / combat / accidents / medical trauma]
• Summary: [Approximate timing, chronicity, perpetrator relationship if relevant] (Provide brief, non-graphic summary sufficient for diagnosis and planning.)
• Current safety: [Ongoing exposure, safe housing, active perpetrator contact]
• Current triggers: [Identified triggers] (Include if identified.)
• Deferred details: [Reason deferred and plan to revisit] (Include if detailed trauma narrative deferred for stabilization or patient preference.)
• Mandatory reporting: [report made / not indicated / will consult] (Document actions taken without unnecessary detail.)

Mental Status Examination

• Appearance: [Dress, hygiene, grooming]
• Behavior/psychomotor: [Activity level, abnormal movements]
• Eye contact: [good / fair / poor / avoidant]
• Speech: [Rate, volume, fluency, articulation]
• Mood: [Patient's words]
• Affect: [Range, intensity, congruence, stability]
• Thought process: [linear / goal-directed / circumstantial / tangential / disorganized]
• Thought content: [Suicidal ideation, homicidal ideation, delusions, obsessions—specify presence or absence]
• Perception: [Hallucinations, dissociative symptoms—specify presence or absence]
• Cognition: [Alertness, orientation, attention, memory]
• Insight: [good / fair / limited] (Include functional examples if clinically significant.)
• Judgment: [good / fair / limited] (Include functional examples if clinically significant.)
• Impulse control: [intact / variable / impaired]

Risk Assessment

Suicide Risk

• Suicidal ideation: [present / absent] (If present, include frequency, intensity, duration.)
• Plan: [Method, timing, access, preparatory behaviors]
• Intent: [present / absent] (Expectation to act, ambivalence, reasons for living vs dying.)
• History: [Prior attempts, aborted/interrupted attempts, method, lethality, recency]
• Current risk factors: [Psychiatric symptoms, substance use, recent losses, isolation, legal/financial stressors, medical illness]
• Protective factors: [Connections, reasons for living, cultural/spiritual factors, treatment engagement]
• Lethal means counseling: [completed / initiated / deferred] (Document specific means and safety steps.)
• Overall suicide risk level: [low / moderate / high] (Provide brief rationale.)
• Mitigation plan: [Safety plan status, crisis contacts reviewed, follow-up interval, higher level of care consideration]

Violence Risk

• Homicidal ideation/targeted threats: [present / absent] (Specify target if present.)
• History of violence: [Summary]
• Access to weapons: [Firearms or other weapons; storage]
• Acute intoxication/command hallucinations: [present / absent]
• Duty-to-protect actions: [taken / not indicated] (Document actions if taken.)

Abuse/Neglect and Vulnerability

• IPV/elder/vulnerable adult concerns: [present / absent] (Assess current safety and resources.)
• Child safety concerns: [present / absent]
• Mandatory reporting: [report made / not indicated / will consult] (Document decisions and actions taken.)

Assessment and Diagnostic Impression

• Primary diagnosis: [DSM diagnosis with specifiers and severity]
• Additional diagnoses: [Including substance use and trauma-related disorders]
• Rule-out/provisional: [Conditions requiring additional information; specify what is needed]
• Differential diagnosis: [Brief summary] (Include only if clinically meaningful.)

Clinical Formulation

[Integrative formulation linking biological, psychological, and social factors] (Use a structured approach. Clearly distinguish observed facts from inferences.)

• Predisposing factors: [Genetic, developmental, family, cultural, or medical vulnerabilities]
• Precipitating factors: [Recent stressors or triggering events]
• Perpetuating factors: [Cognitive, behavioral, interpersonal, or environmental maintainers]
• Protective factors/strengths: [Assets, values, supports, skills]

Medical necessity statement: [Link symptoms, functional impairment, and risk level to expected benefit of psychotherapy at the proposed intensity]

Treatment Plan

• Level of care and modality: [individual therapy / group / family / IOP / PHP / psychiatry referral] (State rationale.)
• Frequency and duration: [Proposed frequency and expected duration with criteria for reassessment]
• Initial goals:
  • [Goal A: specific and measurable with target metric and timeframe]
  • [Goal B: specific and measurable with target metric and timeframe]
  • [Goal C] (Include additional goals only as needed.)
• Planned interventions: [Therapeutic approaches matched to formulation] (For trauma presentations, note if stabilization is prioritized before processing.)
• Coordination of care: [Referrals planned and releases obtained or pending]
• Follow-up: [Next appointment; crisis resources reviewed if risk present]

Medical Services Addendum (90792 Only)

(Include this section only when medical services are provided by a qualified prescriber billing 90792.)

• Targeted review of systems: [Pertinent positives and negatives relevant to psychiatric care]
• Vitals: [BP, HR, weight/BMI, others as obtained]
• Targeted physical exam: [Findings as indicated]
• Labs/diagnostics: [Tests reviewed or ordered with interpretation]
• Medication plan: [Rationale for starting or changing medications; medication name, dose, titration plan; monitoring plan; safety counseling provided; adherence barriers discussed; follow-up interval for medication monitoring]