How to Write Therapy Intake Notes: First Session Documentation Guide

Why the Intake Note Is Different

Every therapy session note matters, but the intake note carries unique weight. It establishes the clinical record, documents informed consent, captures the initial diagnostic impression, and sets the foundation for a defensible treatment plan. When an insurance company wants to audit your practice, the intake note is the first document they ask for.

For new therapists especially, intake documentation is one of the most intimidating parts of the job. This guide breaks down what a complete, defensible intake note includes — and how to write one efficiently.

What Makes an Intake Note Different from a Progress Note

A standard progress note documents a single session in the context of an ongoing treatment relationship. An intake note does something more: it tells the clinical story of why this client is in treatment, what is diagnosable, what the treatment goals are, and how you plan to address them.

The key components unique to an intake note are:

• Biopsychosocial assessment — history that provides clinical context
• Initial diagnostic impression — a DSM-5 diagnosis or working diagnosis
• Treatment plan — what you're targeting and how
• Informed consent documentation — confirming the client understood the terms of treatment

In many practices, the intake note and the initial treatment plan are separate documents. In others, they are combined. This guide covers both scenarios.

The Core Elements of a Complete Intake Note

1. Identifying Information

Document the client's demographics, referral source, and reason for seeking treatment — in general terms that don't rely on memorization of specific details.

Client is a [age]-year-old [gender] presenting for outpatient individual therapy. Referred by [self-referral / PCP / employee assistance program / etc.]. Client reports seeking treatment for [general presenting concern].

2. Presenting Problem

This is the client's own account of why they're here. In their words, with appropriate clinical paraphrasing.

Include:

• Chief complaint (what brought them in now, not just what's been wrong)
• Duration and onset of symptoms
• Precipitating events or stressors
• Prior treatment history (therapy, medication, hospitalizations)
• Prior response to treatment

Example: Client presents with a chief complaint of worsening depression and anxiety over the past six months following job loss and relationship separation. Client reports two prior courses of individual therapy — one in 2018 and one in 2022 — with partial symptom improvement. No prior psychiatric hospitalizations. Client is not currently on psychiatric medication.

3. Biopsychosocial History

This section provides the clinical context that explains the presenting problem. It does not need to be exhaustive on the intake note — you can note that a full biopsychosocial was completed and retained in the chart.

Key areas to at minimum document:

• Family psychiatric history — mental illness in first-degree relatives
• Developmental history — significant childhood trauma, attachment history
• Medical history — current health conditions, medications, substance use
• Social history — current living situation, support system, occupational functioning
• Cultural/contextual factors — relevant identity, cultural, or spiritual factors

4. Mental Status Examination

The MSE is your clinical snapshot of the client at intake. Document all components:

5. Safety Assessment

Every intake must include a thorough safety assessment, documented in detail. This is especially important for clients with mood disorders, trauma histories, or any presentation that could involve SI or self-harm risk.

Document:

• Current suicidal ideation (passive vs. active; intent vs. no intent; plan vs. no plan)
• Prior suicide attempts (if any) — method, lethality, precipitants
• Current self-harm behaviors
• Homicidal ideation (if applicable)
• Access to means (especially firearms)
• Protective factors (reasons for living, social support, future orientation)

If no safety concerns are identified: Client denied suicidal ideation, homicidal ideation, and self-harm urges at intake. No prior suicide attempts or psychiatric hospitalizations. Risk assessed as low at this time.

If there are safety concerns, document them thoroughly including the risk stratification rationale and the safety planning steps taken.

6. Diagnostic Impression

This is where you document your initial DSM-5 diagnosis based on the intake presentation. Include:

• Primary diagnosis with DSM-5 name and ICD-10 code
• Differential diagnoses under consideration if the picture is not yet clear
• Provisional diagnosis language if you're still gathering information

Example: Based on the intake assessment, client presents with symptoms consistent with Major Depressive Disorder, single episode, moderate (F32.1), as evidenced by dysphoric mood, anhedonia, insomnia, fatigue, and difficulty concentrating persisting for at least six weeks with significant functional impairment. Generalized Anxiety Disorder (F41.1) is a co-occurring consideration given endorsed excessive worry and physical anxiety symptoms. Rule out Persistent Depressive Disorder pending extended observation.

7. Treatment Plan Summary

The treatment plan documents the goals, objectives, and interventions for treatment. In some practices, this is a separate document signed by the client; in others, it's summarized in the intake note.

At minimum, document:

• 2–3 measurable treatment goals tied to the diagnosis and presenting problem
• Therapeutic modality and approach planned
• Frequency of sessions
• Estimated duration of treatment (if determinable)

Example goals:

• Goal 1: Reduce depressive symptoms, as measured by a PHQ-9 score below 10 within 12 sessions
• Goal 2: Develop and implement three behavioral activation strategies to improve daily functioning within 8 sessions
• Goal 3: Client will identify and challenge three core negative beliefs contributing to depressive thinking patterns within 16 sessions

8. Informed Consent Documentation

Document that informed consent was obtained and what was covered:

Client was provided with and acknowledged receipt of the informed consent document. Therapist reviewed: nature of services, confidentiality and its limits, HIPAA privacy rights, fee structure and payment policy, telehealth consent (if applicable), emergency contact protocol, and the voluntary nature of treatment. Client verbalized understanding and signed consent.

Putting It Together: SOAP Format for Intake

Many therapists use SOAP format even for intake notes. Here's how the intake elements map onto SOAP:

S (Subjective): Presenting problem — client's chief complaint, symptom description, history in their own words.

O (Objective): Mental status examination findings.

A (Assessment): Diagnostic impression including DSM-5 diagnosis, differential, and risk assessment.

P (Plan): Treatment plan goals, modality, frequency, and initial session focus.

Using AI for Intake Notes

AI documentation tools like TherapNote can dramatically speed up intake note writing. After an intake session, you can dictate a 2–3 minute summary covering the presenting problem, history highlights, MSE findings, diagnostic impression, and planned approach — and receive a complete, structured intake note as a starting point.

The intake note still requires your clinical judgment and review — especially the diagnostic section and safety assessment. But starting from an AI-generated draft rather than a blank page cuts intake documentation time significantly, which matters most during the onboarding rush of a new caseload.

Documentation quality at intake sets the tone for every session that follows. Get it right once, and the rest is easier.