Did you know that your very first progress note should look different from your other client case notes?
That's because the first session with clients, the intake assessment, is very different from our "typical" sessions... whatever "typical" looks like to you ;)
In that first session with mental health clients we have forms to review and information to gather. And there are very important things to discuss with our clients so they understand the counseling process.
I recommend including that you reviewed all of these things in every intake progress note you complete (obviously, with the understand that you actually did review those things with the client in session):
- Limits to confidentiality
- Potential benefits and drawbacks to treatment
- Consent for treatment
- Attendance policy
- Communication outside of session
- Reason for seeking treatment
- Assessment of symptoms
- Assessment of biopsychosocial data
- Plan for treatment
Some sections may have more or less detail, depending on the client's situation or length of the session.
For example, it often takes more time to do an intake for child and adolescent clients because we want to get information from the caretakers, as well as the client. Others simply do a more in-depth assessment and take 2-4 sessions.
When that happens, simply document the portions you did cover (and with whom you discussed it) and then what you plan to cover in the next session. However, I do recommend that you review limits to confidentiality and obtain consent at the first session, whenever possible.
Want to see an example note?
I've got one for you! Check out this sample note below to see how it looks when we put it all together. I'm using the DAP note format here...
Client arrived early and had completed intake paperwork online using client portal. Reviewed with client the limits to confidentiality, potential benefits and drawbacks of treatment, communication outside of session and attendance policies. Obtained consent for treatment. Discussed biopsychosocial history further and completed all intake paperwork. Assessed reason for treatment, current struggles and symptoms. Identified goals for treatment. Current goals include 1) Creating a routine for relaxation and self-care and 2) Identifying priorities and planning for work and home tasks accordingly. Client requested weekly assignments to stay on task so we will use this format to start and evaluate after 6-8 weeks.
Client was comfortable disclosing details about prior treatment and mental health history. Exhibits excellent insight and desire for continued personal growth but is frustrated with ongoing struggles and feels she is not meeting her potential. Previously treated for both depression and anxiety, for which she has created excellent coping strategies and continues to use cognitive-behavioral techniques to address. Currently struggling with symptoms related to ADHD as primary concern.
Client will attend weekly sessions in the office, with the option to move to online sessions if needed. Therapist will assist client in identifying the appropriate weekly “homework” tasks before the end of each session. Client will provide one check-in via journaling in client portal once per week outside of sessions. Weekly assignment is to gather all to do lists and pending tasks to bring in for next session and label with priority level. Next session scheduled for 05/19/17 at 12pm.
You're probably thinking, "Does my note need to be that detailed?"
Maybe not... that all depends on the situation, as well as how in-depth your intake assessment is. For example, if you don't use homework or if you didn't have time to review treatment goals, this note would be a lot shorter.
On the flip side, if you had to do an assessment of safety because the client reported feeling suicidal, your note might actually be longer.
Notice that this note doesn't include anything I would have in my intake assessment form.
That's because I see no reason to write the same thing multiple times!
This used to drive me crazy when I worked in an agency. And it's a reason that soooo many therapists resent paperwork and fall behind. That's why I recommend you streamline your documentation as much as possible.
If you have questions about substance abuse, past treatment, relationships, and suicidal ideation then why do you need to write these things over again in your intake note? My opinion is that you don't need to duplicate this... but you do need to have it documented somewhere that makes sense.
So, if you miss something on your intake assessment form then write it in your intake progress note and vice versa.
I've got a checklist you can download to create your own intake note template or to use as a reminder when writing your intake notes.
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