Therapy Intake Session Template
Description:
This template offers a structured framework for therapists conducting an initial intake session, designed to collect essential patient information in a thorough and professional manner. It provides detailed guidance within brackets to explain the purpose and scope of each section, ensuring clinicians can capture a holistic picture of the patient’s needs while maintaining flexibility to adapt to individual circumstances.
Note:
This template is a flexible guide for professionals. Sections can be reordered or omitted based on the session’s flow and the patient’s presentation.
Date: [Record the date of the intake session for documentation and reference purposes]
Patient Name: [Enter the patient’s full legal name to ensure accurate identification.
Therapist Name: [Enter the therapist’s full name to establish accountability and ownership of the session notes]
Consent and Confidentiality: [Document the patient’s understanding and agreement to the therapy process, including the scope of confidentiality, limits such as mandatory reporting for harm, and compliance with regulations like HIPAA, noting any signatures if required by practice standards.]
Patient Information
Patient Name: [Enter the patient’s full legal name as provided, ensuring clarity for record-keeping and future correspondence]
Date of Birth: [Record the patient’s date of birth in MM/DD/YYYY format to establish their age, which provides context for developmental and life-stage considerations]
Emergency Contact: [Provide the full name, relationship to the patient, and current phone number of a designated emergency contact, ensuring accessibility in case of urgent situations requiring immediate outreach
Presenting Problem & History
Chief Complaint: [Describe in detail the primary issues or concerns that led the patient to seek therapy, capturing their own words or perspective to reflect their subjective experience and priorities]
Onset and Duration: [Note when the current symptoms or problems first emerged, how long they have persisted, and any patterns or fluctuations over time, providing a timeline to assess chronicity and triggers]
Medical/Psychiatric History: [List all relevant past or current medical conditions and psychiatric diagnoses, including dates, sources of diagnosis, and treatments received, to build a comprehensive health background that informs therapy planning]
Family History: [Indicate whether there is a known history of mental health conditions in the patient’s immediate or extended family, specifying disorders or patterns if relevant, to evaluate potential genetic predispositions or environmental influences on the patient’s mental health]
Previous Treatments: [Detail all prior mental health interventions, such as therapy, counseling, or medications, including their duration, outcomes, and any reported side effects, to understand what has been effective or challenging in the past]
Current Functioning
Sleep: [Describe the patient’s current sleep habits, including quality, duration, consistency, and any disturbances such as insomnia, nightmares, or excessive sleep, as these can indicate underlying mental health issues]
Appetite: [Note the patient’s current appetite levels, any recent changes in eating habits or weight, and whether these shifts correlate with emotional or psychological states, to assess physical manifestations of distress]
Energy: [Record the patient’s typical daily energy levels, including any reports of fatigue, lethargy, or hyperactivity, to gauge their physical and emotional capacity for daily functioning]
Mood: [Summarize the patient’s predominant mood over recent days or weeks, including its stability or variability, as observed in-session and reported, to establish a baseline for emotional well-being]
Risk Assessment
[Document any current or past thoughts of suicidal ideation, self-harm, or harm to others, including the frequency, intensity, intent, and any protective factors like support systems or coping strategies, to prioritize safety planning and determine the urgency of intervention.]
Mental Health History
Past Therapy: [Note any previous experiences with therapy or counseling, including the type, duration, frequency, and the patient’s subjective impression of its effectiveness or challenges, to contextualize their expectations and past engagement]
Diagnoses: [List all prior mental health diagnoses received from professionals, including approximate dates and sources, to track the patient’s mental health trajectory and inform current diagnostic considerations]
Hospitalizations: [Detail any past psychiatric hospitalizations, including dates, reasons such as acute episodes or crises, and outcomes like stabilization or ongoing issues, to assess the severity and history of mental health challenges]
Medical History
Medications: [List all medications the patient is currently taking, including dosage, frequency, and purpose, whether for mental health or physical conditions, to evaluate potential interactions or side effects relevant to therapy]
Conditions: [Record any chronic or significant physical health conditions, such as diabetes, chronic pain, or neurological issues, that may influence mental health or the therapeutic process]
Recent Events: [Note any recent surgeries, hospitalizations, or major medical events, including dates and reasons, as these may impact the patient’s current emotional or physical state and therapy focus]
Family and Social History
Family: [Describe the patient’s family structure, key relationships, and significant dynamics or events, such as divorce or loss, to understand their upbringing and current familial context]
Support: [Note the availability and quality of the patient’s social support network, including friends, family, or community groups, to assess external resources that may aid or hinder therapy]
Interests: [List activities, hobbies, or pursuits the patient enjoys or finds meaningful, as these can serve as strengths, coping mechanisms, or areas to explore in treatment]
Strengths: [Highlight the patient’s personal strengths, talents, or sources of joy and pride, to identify positive attributes that can be leveraged in therapy for resilience and motivation]
Cultural/Contextual Factors
[Document any cultural, religious, ethnic, or socioeconomic factors that may shape the patient’s identity, experiences, or mental health needs, such as beliefs about therapy or systemic stressors, to ensure a culturally sensitive and tailored approach.]
Substance Use
Alcohol: [Record the frequency, quantity, and context of alcohol consumption, noting any concerns raised by the patient or therapist about its impact on their life or mental health]
Drugs: [Detail any use of recreational or illicit drugs, including types, frequency, and patterns of use, to evaluate their role in the patient’s current functioning or challenges]
History: [Note any past or current struggles with substance abuse, including treatment attempts, periods of sobriety, or relapses, to assess the extent of substance-related impacts]
Goals for Therapy
Hopes: [Describe what the patient hopes to achieve through therapy in broad terms, capturing their overarching aspirations or motivations for seeking help]
Changes: [Note specific behavioral, emotional, or situational changes the patient desires, providing concrete focus areas for therapeutic work]
Progress: [Identify how the patient envisions measuring success or improvement, such as reduced symptoms or enhanced quality of life, to align expectations and track outcomes]
Patient Questions: [Record any questions the patient has about the therapy process, its structure, or expected outcomes, as well as any additional concerns or experiences they wish to share, ensuring their voice is fully captured]
Next Steps: [Outline the proposed frequency and duration of future sessions, what the patient can expect in the initial weeks, and how they can contact the therapist between sessions, such as via phone or email, to establish clear next steps and continuity]
Summary: [Summarize the therapist’s initial impressions of the patient’s situation, integrating key themes, strengths, and challenges from the session, to provide a cohesive overview for future reference]
Plan: [Detail the preliminary treatment approach, including potential techniques, focus areas, or immediate actions like referrals, as well as any topics requiring deeper exploration, to guide the therapeutic process moving forward]
Therapy Intake Session Template (Filled Mock Session)
Description:
This template offers a structured framework for therapists conducting an initial intake session, designed to collect essential patient information in a thorough and professional manner. It provides detailed guidance within brackets to explain the purpose and scope of each section, ensuring clinicians can capture a holistic picture of the patient’s needs while maintaining flexibility to adapt to individual circumstances.
Note:
This template is a flexible guide for professionals. Sections can be reordered or omitted based on the session’s flow and the patient’s presentation.
Date: February 25, 2025
Patient Name: Jane Doe
Therapist Name: Dr. Emily Carter, LPC
Consent and Confidentiality: Jane verbally confirmed her understanding of the therapy process, including confidentiality and its limits (e.g., mandatory reporting for imminent harm). She agreed to proceed and signed the practice’s informed consent form, which aligns with HIPAA requirements.
Patient Information
Patient Name: Jane Doe
Date of Birth: 03/15/1990
Emergency Contact: Michael Doe, Husband, 555-123-4567
Presenting Problem & History
Chief Complaint: Jane reports feeling “overwhelmed and anxious constantly,” citing work stress and difficulty relaxing as her main reasons for seeking therapy. She describes it as a “tight knot in my chest that won’t go away.”
Onset and Duration: Symptoms began approximately 18 months ago after a promotion at work increased her responsibilities. She notes the anxiety has worsened over the past 6 months, with daily episodes of worry and occasional panic attacks.
Medical/Psychiatric History: Jane has no chronic medical conditions but was diagnosed with generalized anxiety disorder by her primary care physician in 2023. No other psychiatric diagnoses were reported.
Family History: Jane’s mother has a history of depression, treated with medication since Jane was a teenager. Her paternal grandfather struggled with alcoholism, though details are unclear. No other known mental health issues in the family.
Previous Treatments: Jane saw a counselor briefly in college for stress (6 sessions, “somewhat helpful”). She tried Zoloft (25 mg) prescribed by her PCP in 2023 for 3 months but discontinued due to nausea and lack of noticeable improvement.
Current Functioning
Sleep: Jane reports sleeping 5-6 hours per night, often waking up at 3 a.m. with racing thoughts. She describes difficulty falling back asleep and feels unrested most days.
Appetite: Her appetite has decreased over the past 3 months; she skips meals when stressed and has lost 8 lbs unintentionally. She eats mostly convenience foods due to time constraints.
Energy: Jane describes low energy, particularly in the afternoons, feeling “drained” by work demands. She pushes through but crashes on weekends.
Mood: Predominant mood is anxious and irritable, with moments of sadness when reflecting on her workload. She rates her mood as “4 out of 10” most days, with occasional dips to 2.
Risk Assessment
Jane denies any current or past suicidal ideation, self-harm, or thoughts of harming others. She says, “I’d never do that—I just want to feel normal again.” Protective factors include her supportive husband and desire to improve for her young daughter.
Mental Health History
Past Therapy: In college (2010), Jane attended 6 sessions with a campus counselor for academic stress; she found it “nice to vent” but didn’t continue due to scheduling. No other therapy history.
Diagnoses: Generalized Anxiety Disorder, diagnosed by PCP in October 2023 based on persistent worry and physical symptoms like palpitations.
Hospitalizations: No history of psychiatric hospitalizations or acute mental health crises requiring inpatient care.
Medical History
Medications: Currently takes no medications. Previously on Zoloft (25 mg daily) from October to December 2023, discontinued due to side effects.
Conditions: No chronic conditions. Reports occasional migraines, managed with over-the-counter ibuprofen as needed.
Recent Events: No recent surgeries or hospitalizations. Last medical event was a routine physical in November 2024, with normal results.
Family and Social History
Family: Jane grew up in a two-parent household with one younger sister. Parents divorced when she was 12; she remains close to her mother, distant from her father. Married to Michael since 2016, with a 4-year-old daughter, Lily.
Support: Strong support from her husband, who encourages therapy, and a best friend she sees monthly. Limited broader network due to work demands.
Interests: Jane enjoys reading mystery novels and gardening, though she hasn’t had time for either lately. She misses these “escapes.”
Strengths: Jane is proud of her career success (marketing manager) and her resilience as a mother. She finds joy in her daughter’s milestones.
Cultural/Contextual Factors
Jane identifies as a white, middle-class American with no strong religious affiliation, though raised loosely Christian. She notes workplace pressure as a woman in a male-dominated field may contribute to stress, feeling she must “prove herself” constantly.
Substance Use
Alcohol: Drinks 1-2 glasses of wine 2-3 times per week, typically to unwind. Denies excessive use but notes it’s increased slightly in the past year.
Drugs: No recreational or illicit drug use was reported. Denies past experimentation beyond trying marijuana once in college.
History: No history of substance abuse or dependency. Alcohol use remains within social limits, per her report.
Goals for Therapy
Hopes: Jane wants to “feel in control again” and reduce her constant worry so she can enjoy life with her family.
Changes: Specific goals include fewer panic attacks, better work-life balance, and improved sleep quality.
Progress: She’ll know therapy is working if she can “get through a week without feeling like I’m drowning” and spend more relaxed time with her daughter.
Patient Questions: Jane asked, “How long will it take to feel better?” and “Will I need medication again?” She also shared feeling guilty for not managing stress on her own.
Next Steps: Weekly 50-minute sessions scheduled for Tuesdays at 3 p.m., starting March 4, 2025. Jane can expect initial focus on anxiety management techniques. She can email me at emily.carter@therapypractice.com or call 555-987-6543 for urgent needs between sessions.
Summary: Jane is a 34-year-old married woman presenting with generalized anxiety exacerbated by work stress over the past 18 months. She’s motivated for change, with strengths in her family support and self-awareness, though challenged by poor sleep, low energy, and guilt. No immediate safety concerns.