A Step-by-Step Guide to the Therapy Intake Process
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Looking for a step-by-step guide to the therapy intake process? If so, we’ve got you covered.
Once you’ve made it past the screening phase with a client, it’s time for the behavioral health intake process.
The first appointment, or the intake session, is a time to build rapport with clients, gather relevant information about them, and lay the groundwork for therapeutic work together.
It can be a juggling act to build connection with a client while collecting the appropriate information and documenting what is being shared. Therefore, having a successful behavioral health intake process can help to make onboarding new therapy clients smoother and simpler.
In this step-by-step guide to the therapy intake process, we cover how to prepare for intake sessions, tips for writing intake notes, therapy intake questions, and more.
This article also includes a free downloadable intake note template that you can save to your electronic health record (EHR) for future use with clients.
Before the first session
Prior to the therapy intake appointment, clients will need to review and sign some forms.
Many EHR systems, such as SimplePractice, have tools to easily send these electronically to the client for their review and digital signature.
These intake forms for therapy typically include:
- Informed Consent
- Practice Policies
- Notice of Privacy Practices
- Good Faith Estimate of Fees
- Emergency Contacts and Resources
- Client Contact and Demographic Information
- Electronic Communication Consent
- Telehealth Consent (If Applicable)
- Credit Card Authorization
- Intake Questionnaire
- Any State Specific Mandated Disclosures (For example, Colorado)
To ensure having all the necessary forms with appropriate language, it can be helpful to consult with a lawyer. It is essential that clinicians have a secure, HIPAA-compliant storage system for all of the forms—as well as a secure way to share them electronically with clients.
SimplePractice offers customizable paperless intake forms that can be sent to clients and signed electronically via a secure, HIPAA-compliant Client Portal.
Mental health assessments (such as the GAD-7, PHQ-9, PCL-5) can be sent out in advance as well, or conducted in session with the therapist. In SimplePractice, these measurement-based care tools also have automated sending, scoring, and reporting.
Once these forms are completed by the client, it is important for the clinician to review them, particularly the intake questionnaire, before the client’s first appointment. This prevents the client from having to restate information that they have previously shared in their intake paperwork.
The information shared by the client in advance can also give therapists some discussion topic ideas for the first appointment.
The therapist can also prepare for the session by writing down questions they want to ask the client or additional assessments they want the client to take based on what they shared on their consultation call or in the intake forms.
What to do when your new client arrives
First impressions in session with a new client are crucial.
Greeting the client and making them feel welcome in therapy is essential. It is important that the client knows that therapy is a safe, welcoming environment, especially as they are preparing to share very personal information with you.
Next, lay out the structure and purpose of the intake session to help put the client at ease. Let them know that, as the therapist, you have a plan for the session and will help guide them through it.
The next step before gathering information will be to discuss informed consent with the client. This is where the clinician will share the limits of confidentiality, risks and benefits to therapy, key expectations and policies, as well as telehealth risks and policies (if applicable).
During this part of the appointment, the therapist will verbalize much of what is written in the informed consent intake form to ensure the client understands and to receive verbal acknowledgement and agreement from the client.
Finally, at the end of the session, it can be helpful to offer the client the chance to ask any questions they may have before the therapist begins with their intake questions. This can give the client some agency and the chance to clear up any of their own concerns or confusion.
How to write therapy intake notes
A therapy intake note is the documentation for your first intake session. It will capture all of the information that the client describes to you.
This information will include a well-rounded picture of the client in various domains of their life. It can be helpful for the therapist to view themselves in these sessions like an investigative reporter who is trying to understand and represent the experience of the person being interviewed. The intake note should give a full picture of the client’s view of their own life.
The intake note is best captured by using some form of template, such as the free downloadable intake note template at the top of this step-by-step guide to the therapy intake process.
Using a template can take the pressure off of the clinician to have to memorize all of the categories of information to cover.
The intake note template can set a structure for the first session, as the therapist will know everything that needs to be discussed. Some therapists prefer to type and document as they go through the discussion, while others prefer to take abbreviated notes and focus more on the dialogue with the client.
Either approach can work, as long as the dual objectives of building rapport with the client and capturing adequate information are being met.
What information is included in the intake form?
Several important areas of a client's life should be documented in the intake form. A good place to start is with the client’s presenting problem, including their major complaints and symptoms. This will capture what they are struggling with and why they are coming to therapy. Asking follow-up questions about their experience can help to clarify the client’s daily experience, symptoms, and life impairments.
When capturing this information, using empathic and reflective listening can help establish credibility for the therapist and trust from the client.
Historical information is also important to ask clients during the therapy intake session. Establish the history of the presenting problem and your client’s symptoms, along with any previous mental health diagnoses.
Other necessary historical components include understanding family mental health background, as well as family relationships and any trauma history.
Gathering a medical and substance use history from the client is also essential to rule these out as contributing factors to the client’s symptoms and impairments.
Gaining understanding of any prior mental health treatment can help determine what the client has been dealing with and inform the therapist of any approaches that have previously been useful or haven’t worked.
A major aspect of the client’s life that also needs to be documented is their social world and community. Understanding the current relational landscape of a client's life can be very illuminating. It is helpful to know about the current state of family relationships, friendships, romantic partners, mentors, and other community relationships.
Spiritual practices and beliefs are core to the culture of many clients, so it is important to ask about and understand these as well. It is helpful to note any cultural or spiritual practice that the client may want to incorporate into their therapy.
To get a well-rounded picture of the client, discuss and note positive aspects of clients. This includes achievements in their life, things they are proud of, or hobbies they participate in. Touch on the strengths of the client and internal resources that they already possess. These can be very effectively weaved into the fabric of the therapeutic work together.
Lastly, understand the current state of a client's housing, job status, general financial situation, education level, and any legal challenges they’ve faced. These are major factors that impact mental health and also might call for additional supportive resources.
Client assessments
During the therapy intake process, it can be helpful to have the client complete some brief assessments to bring in more objective measures of a client's symptoms.
Examples of some of the most commonly used assessments are:
- PHQ-9 for depression
- GAD-7 for anxiety
- PCL-5 for trauma
These assessments can be sent to clients in advance of the first session or after the intake session if time does not allow it during the session.
Examples of therapy intake questions
The following is a list of some useful therapy intake session questions for therapists to ask clients:
- What have you been experiencing recently that is bringing you to therapy?
- What is the frequency, duration, and intensity of these experiences?
- How do these experiences impact your daily life?
- When did these experiences first start for you?
- Do you currently have any major stressors in your life? (Financial, housing, legal, etc.)
- Have you or anyone in your family ever been diagnosed with a mental health disorder?
- Have you previously done any therapy? What was helpful or unhelpful during those previous therapy experiences?
- Do you have any medical conditions that affect your daily life or mental health?
- Do you have any history of substance use?
- Do you currently drink alcohol or use drugs? If so, how much and how frequently?
- What was your family life like growing up?
- Did anyone ever harm you in any way as a minor?
- Who are the closest relationships and supports in your life right now?
- Are there any cultural or spiritual practices that are important in your life? Would you like to incorporate any of them into therapy?
- What are your best qualities? What do you like most about yourself?
Common challenges with intake notes
Completing an effective intake session and notes can include some challenges.
One major challenge during the therapy intake process is finding the balance between rapport building and information gathering.
Too much rapport building and the clinician may feel like they didn’t learn enough about the client.
But if there’s too much information gathering, the client may leave the session feeling disconnected from the therapist or like they just survived an interrogation.
Another challenge can be navigating clients who give very short or very long-winded responses. For those who give terse answers, therapists should remain attentive to make that client feel comfortable and ask further questions to elicit more information.
For clients who give long answers or extraneous details, the therapist will need to be effective with redirecting the client and keeping the intake questions moving along.
Another challenge, particularly for clients with insurance, is that they may require a diagnosis after the first session. This can prove difficult at times because the clinician may feel that they need more time with the client or more information in order to make a determination.
In these instances, a clinician can make the best diagnosis possible given the information provided, keeping in mind that the diagnosis can be updated later as more information becomes available.
Wrapping up the first session
As the first session comes to a close, there are several helpful things to discuss.
For example, it is necessary to discuss the client’s goals for therapy. If the client provides vague answers, ask clarifying questions to help make the goals as specific as possible. Define specific, time bound, and measurable objectives that will form the structure of the treatment plan.
Next, check in with the client and ask how they feel after sharing so much about their lives. Give the client some space to process the session. Being attentive to their feelings can go a long way toward building rapport and comfortability.
Clinicians should also give clients another opportunity to ask any final questions that may have arisen throughout the session. Finally, provide a brief preview of what will happen in the next session and give the client some things to consider before that session.
With a good intake note template, the right questions, and some intentional care, therapists can come out of the behavioral health intake process with a full picture of their client and a great foundation of rapport to build upon.
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