The intake note is the most important document in a client’s file. Everything that follows — every session note, every treatment plan update, every termination summary — builds on what you capture in those first 50 minutes. And yet intake documentation is where therapists most often cut corners, usually because the first session is cognitively demanding enough without worrying about what to write down afterward.
This guide covers what to document, how to structure it, and what experienced clinicians wish they’d known when they were starting out.
Why the first session note is different
Regular session notes document what happened in a specific session. The intake note does something more: it establishes the clinical baseline for the entire treatment relationship.
A well-written intake note answers five questions:
- Who is this person and why are they seeking therapy now?
- What is the relevant history — mental health, medical, relational, trauma?
- What is their current level of functioning?
- What is my initial clinical picture?
- What are we working toward together?
If a colleague had to take over this case next week, your intake note should give them enough to walk into that session prepared. If it doesn’t, it’s not complete.
What to document: section by section
Presenting problem
Start with the client’s own words. Why are they here, in their language, not your clinical reframe.
“Client described feeling ‘stuck in the same patterns’ across relationships, noting: ‘I always end up invisible.’ Sought therapy following the end of a three-year relationship four months ago.”
Note the precipitating event if there is one — what changed or happened that prompted them to make the call now, rather than six months ago or six months from now. This often reveals something clinically important about the client’s threshold for seeking help.
Relevant history
Cover the following briefly — not an exhaustive biography, but enough to contextualize the presenting problem:
- Mental health history: prior diagnoses, previous therapy (what helped, what didn’t, why they left), hospitalizations, psychiatric medications past and present
- Medical history: chronic conditions, current medications, anything that may intersect with psychological presentation
- Family history: mental health in family of origin, quality of early attachment relationships, significant losses or disruptions
- Trauma history: ask directly, document what the client discloses at this stage — you don’t need the full narrative in session one, but you need to know whether trauma is part of the picture
- Substance use: current use, history of problematic use, any active concerns
Keep this section factual and specific. “Reported history of depression” is less useful than “Client reports two prior depressive episodes — ages 19 and 26 — both lasting approximately eight months, neither treated with medication or therapy.”
Current functioning
Snapshot the client’s life across key domains at the time of intake:
- Work/school: stability, satisfaction, current stressors
- Relationships: primary relationship status, quality of social support, significant conflicts
- Sleep and appetite: disruptions, patterns
- Physical activity and self-care
- Substances: current use patterns
This baseline is what makes later notes meaningful. When you write in session eight that the client’s sleep has “significantly improved,” the intake note is what makes that claim verifiable.
Mental status observations
Document what you observed during the session — not what the client reported, but what you saw:
- Appearance and behavior: grooming, psychomotor activity, eye contact
- Speech: rate, volume, coherence
- Mood (client’s self-report) and affect (your observation) — note congruence or incongruence
- Thought process: linear, circumstantial, tangential, loose
- Thought content: preoccupations, obsessions, delusions if present
- Perceptions: any reported hallucinations
- Cognition: orientation, apparent memory and concentration
- Insight and judgment
You don’t need to write a paragraph for each — a sentence or two per relevant area is enough. But don’t skip this section. Mental status at intake is the clinical baseline against which all future observations are measured.
Risk assessment
Document this explicitly, even if — especially if — risk is absent.
Assess and document for:
- Suicidal ideation (passive and active), intent, plan, means access
- Homicidal ideation
- Self-harm
- Any current crisis
Include how you assessed (direct inquiry is the standard), what the client reported, and your clinical judgment.
“Suicidal ideation assessed by direct inquiry. Client denied current SI, passive ideation, HI, and self-harm. No history of attempts. Identified strong protective factors: two close friendships and stated commitment to ‘figuring this out.’ Risk assessed as low at this time.”
If risk is elevated, document your safety planning in detail.
Informed consent and logistics
Note that informed consent was reviewed, that the client had the opportunity to ask questions, and that they agreed to proceed. Document any releases of information signed. Note session frequency agreed upon and any coordination with other providers planned.
Preliminary clinical formulation
This is where you make the intake note clinically valuable rather than just administratively complete.
In two to four sentences: what is your initial understanding of this client’s presentation? What patterns do you notice? What hypotheses are you holding? What do you want to learn more about?
“Initial picture: chronic difficulty with emotional expression and direct assertion of needs, potentially rooted in described family dynamics where emotional display was ‘not allowed.’ Presenting loss may have activated underlying schema around invisibility and unworthiness. Will explore early relational patterns and assess for dysthymia vs. MDD with persistent features. Curious about the role of the client’s perfectionism as both adaptive and maintaining factor.”
This section is for you as much as for the record. Writing it forces the kind of clinical thinking that makes the second session better.
What experienced therapists document that new therapists miss
The client’s own framing of their goals. Not what you think they need — what they said they want. “Client stated goal: ‘I want to stop shrinking myself around people I care about.’” You’ll return to this exact phrase over the course of treatment.
What didn’t come up. If a client notably avoided a topic — didn’t mention family, deflected when asked about relationships, minimized something significant — note it. Omissions are clinical data.
Your own countertransference, briefly. Not in the official note if your EHR is accessible to clients. But in a private process note: what did you feel during the session? What felt charged? This is where supervision starts.
The “why now” in detail. What specifically changed that brought this client in at this moment? This question often unlocks the most clinically important information of the intake.
A practical intake note structure
Date: [date]
Session type: Intake / Initial Assessment
Duration: [50 / 90 min]
Presenting problem:
[Client's own words + precipitating event]
Relevant history:
[Mental health / Medical / Family / Trauma / Substances — brief]
Current functioning:
[Work / Relationships / Sleep / Substances — snapshot]
Mental status:
[Appearance, Speech, Mood/Affect, Thought, Risk]
Risk assessment:
[Method, findings, clinical judgment, safety plan if applicable]
Informed consent:
[Reviewed, client questions addressed, agreement confirmed]
Preliminary formulation:
[2–4 sentences: initial clinical picture, hypotheses, questions to pursue]
Plan:
[Session frequency, treatment focus, referrals, next session date]The note you’ll be glad you wrote
The intake note you write in the first 20 minutes after a session will be read again — at termination, in supervision, in a peer consultation when something shifts unexpectedly, possibly in a legal proceeding you can’t anticipate. It will be the document that shows whether you understood this client from the beginning.
The most common regret experienced therapists have about early documentation isn’t that they wrote too much. It’s that they wrote too fast, too vaguely, and lost the details that would have mattered later.
Slow down for the intake. It’s worth it.