Whenever I meet with clients for the first time, I make sure to have a form with me so I stay on track. Even though I've done tons of assessments using the same form, it's so easy to miss something important when I don't have that friendly reminder.
Having a good intake assessment form is crucial to doing a good intake assessment. Ideally, the form simply serves as a means to guide and document your clinical conversation. It's a valuable tool in the moment, and also if you need to remember things down the line.
That being said, creating the form can take a bit of work to individualize and then there's the task of familiarizing yourself with it so you actually focus on the client during your intake, not the form.
That's why we're breaking things down in this post. I'm going to review with you each of the sections of the intake form in my Therapist's Perfect Paperwork Packet so you can identify which sections in your form you may need to add more detail or which areas to take away some extraneous information.
Note: People use different terms for this form but the form I'm talking about is your clinical assessment, or biopsychosocial assessment, completed during the intake phase of treatment (typically, the first 1-4 sessions).
Client Contact Information
You may have this elsewhere in your intake paperwork but I like having some details on client demographics directly on the assessment itself. How in depth you go depends on the information you feel is important to your practice. You'll at least want to include basic contact information, emergency contact information and how to best reach your client (including whether or not voicemails and texting is okay).
Other things you may want to consider are languages spoken, ways in which your client found you, military rank/position, email, work phone number, etc. Think about the things you wish you had asked before or info you found helpful and include that.
I like having a section that allows the client to describe themselves a bit. This way you get to see the language your client uses for things like hobbies and interests. You can also ask for personal strengths or for preferences. You may want to ask about things like typical screen time or favorite games if you see children.
I also include a section here for clients to describe their goals for treatment. This way you get to see what their thoughts are about therapy in general and why they've come to see you, in particular. This serves as a great starting point for discussion.
Gathering information about family history is very important for determining the level of familial support a client has, as well as potential indicators for patterns of behavior. You'll want to identify key relationships, especially those that include an aspect of dependence like care-taking for children or elderly parents.
One important thing to consider here is that everyone has a different definition of family. I always include a question about "who lives at home?" so I capture anything I may be missing. You may also want to go more in-depth and have clients describe (or circle options) about their level of closeness with different family members.
This area may change greatly based on your client population. Obviously, if you see children you would choose to focus more on the education aspect. However, you may want to include a question about the parent/guardian's occupation.
We can get even more detailed here: If you see children who tend to be involved with special education services, you may ask more detailed questions about behavior at school, classroom setting, previous grade retention, etc. But, for example, if you tend to see adolescents with anger problems you may focus more on interpersonal interactions ask about suspensions.
When working with adults, employment can sometimes indicate being part of a sub-culture, like with people in the military. In this case, consider questions that would be client specific but potentially impactful to treatment. In the military example, you may want to ask about rank, length of stay in current assignment and any deployments.
Or perhaps you see women who often describe themselves as "stressed" and so you choose to add a question about typical hours spent at work each week and/or a rating of their current work stress. Likert scales are very easy to use here (e.g. a range from "Very Stressed" to "Not Stressed").
Hopefully, you're beginning to notice how all of these questions easily intertwine with the clinical topics you'd want to discuss during your assessment phase and also allow you to see how this process can naturally flow, rather than just sound like paperwork review.
This is another topic that will vary greatly depending on your typical client population. If you work with elderly clients, for example, you may want to ask more detailed questions about medical history. Likewise, if you work with couples who are having difficulty with their sexual relationship you'd want to make sure each member of the couple has had a physical exam very recently.
This is also where you'll want to get information about your client's physician and psychiatrist, if applicable. Many insurance companies particularly look for you to gather this information so you can collaborate as a treatment team.
Mental Health Treatment History
One of the key things to consider with new clients is whether or not they've been in counseling before. This is important to discuss as you inform clients about what it's like to work with you and whether or not you'll be a good fit.
See what we're doing now? We're integrating informed consent with our intake assessment! Documentation is such a beautiful thing ;)
What are their feelings about coming to counseling? Have they had negative or positive experiences in the past? Are they hoping to revisit similar issues or focus on something very different? What did they like (or dislike) about their previous experience and what did they find helpful?
You may not include all of these questions but consider what typically arises with clients when you discuss these things. What would be helpful to have clients consider ahead of time so you can address it easily during intake? Those are the questions to include.
Substance Use History
Again, depending on your typical client you may add more or less detail here but regardless, it's very important to cover with clients. If you see clients where this is a common issue then you may have a whole page where ask people to identify use of certain types of drugs, daily or weekly amount of use and prior use.
You'll also want to ask about whether or not your client is connected with any other support, like a peer support group or substance rehabilitation program. If so, you'll also want to consider whether or not it may be appropriate to consult with these professionals and how your client feels about that.
There are plenty of other topics to discuss with your clients but you can't know it all before you actually begin the work. The consideration here is whether or not you think it's something to know from the outset or decide if it's something that may come up naturally during the course of treatment.
Topics also included in my intake assessment form are things like religious affiliations, spirituality, coping skills and favorite habits for self-care. I also include a question on whether or not a client has ever been arrested and if they have a current parole/probation officer.
Another important thing to consider (that may also be part of your informed consent) is whether or not your client is currently part of any litigation/court case. Definitely something you want to know as early as possible so you can review any potential conflicts or expectations of the client.
So whether you prefer to create your own form from scratch, revise whatever you have now, or purchase my Paperwork Packet, you've got plenty of options for how you can make the intake process individualized to your clients and your practice.
That's my biggest piece of advice for every aspect of your documentation... make sure it actually makes sense and isn't completed "just to do it." Paperwork has meaning but that's only as deep as the meaning you assign it.
What other topics do you include in your intake form? Comment below and share your own tips!