Initial Intake Assessment

Comprehensive initial assessment for new clients

intake assessment new client history
Intake Forms

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1

Demographic Information

  • Name: [Full Name]
  • Date of Birth: [DOB]
  • Contact: [Phone/Email]
  • Emergency Contact: [Name/Phone]
2

Presenting Concerns

  • Primary concerns: [Description]
  • Duration: [How long]
  • Severity: [1-10 scale]
  • Impact on functioning: [Description]
3

Psychiatric History

  • Previous diagnoses: [List]
  • Previous treatment: [Details]
  • Medications: [Current/past]
  • Hospitalizations: [If any]
4

Family History

  • Mental health in family: [Details]
  • Substance use in family: [Details]
  • Medical conditions: [Relevant conditions]
5

Social History

  • Living situation: [Description]
  • Employment: [Status]
  • Relationships: [Current status]
  • Support system: [Description]
6

Substance Use

  • Current use: [Details]
  • Past use: [Details]
  • Impact: [How it affects life]
7

Risk Assessment

  • Suicidal ideation: [Assessment]
  • Homicidal ideation: [Assessment]
  • Self-harm: [Assessment]
  • Safety plan: [If needed]
8

Treatment Goals

  • Client's stated goals: [List]
  • Expectations: [What client expects]
  • Motivation: [Level and factors]

How to Use This Template

  1. 1

    Review the template structure

    Familiarize yourself with the sections and their purposes before your session.

  2. 2

    Customize for your practice

    Click "Edit & Download" to modify the template to fit your specific needs and clinical approach.

  3. 3

    Save and reuse

    Download as PDF for immediate use, or use within HIPAAtherapy to auto-fill client details and save to your records.

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