Templates / Intake
Intake Session Note Template
A structured first-session note: presenting concerns, history, risk and protective factors, initial impressions, and a treatment plan.
The intake note is the longest note you will write for a client, and the one you will re-read most. It sets the baseline for everything that follows: what they came in for, what has happened before, what the risks are, and what you intend to do.
This template is deliberately broader than a progress note. Use the sections you need; leave the rest empty rather than padding them.
The template
- Presenting ConcernsWhy the client is here now, in their words, plus onset, duration, and what made them seek help at this moment.
- Relevant HistoryMental-health history, prior treatment, medical factors, family history, and relevant life context. Only what is relevant to the presenting concern.
- Risk & Protective FactorsSuicide and self-harm screening, risk to others, substance use, and the strengths and supports that protect the client.
- Initial ImpressionsYour preliminary clinical formulation and, where appropriate, provisional diagnosis. Mark it as provisional.
- Treatment PlanProposed approach, frequency, initial goals, and measures you will use to track progress.
- Follow-UpsAdministrative and clinical to-dos after intake.
Copy these headings into your notes app, or use them built-in in AfterSession.
When to use it
Use it for the first one or two sessions with a new client, or when re-opening a case after a long gap. Switch to SOAP, DAP, or BIRP for ongoing sessions.
Section-by-section guide with example
Presenting Concerns
Why the client is here now, in their words, plus onset, duration, and what made them seek help at this moment.
Relevant History
Mental-health history, prior treatment, medical factors, family history, and relevant life context. Only what is relevant to the presenting concern.
Risk & Protective Factors
Suicide and self-harm screening, risk to others, substance use, and the strengths and supports that protect the client.
Initial Impressions
Your preliminary clinical formulation and, where appropriate, provisional diagnosis. Mark it as provisional.
Treatment Plan
Proposed approach, frequency, initial goals, and measures you will use to track progress.
Follow-Ups
Administrative and clinical to-dos after intake.
The example is a fictional composite written for illustration. It does not describe a real person.
Common mistakes
- Writing the intake as a life story. Relevance to the presenting concern is the filter.
- Skipping the risk screen because "they seemed fine". Document that you asked, and what they said.
- A treatment plan without measurable goals. "Feel less anxious" cannot be reviewed; "GAD-7 below 10" can.
Frequently asked questions
How long does an intake note take to write?
Typically 20–30 minutes. Many therapists complete the factual sections during the session (with the client's knowledge) and write impressions and plan afterwards.
Should I include a diagnosis in the intake note?
If you are qualified to diagnose and have enough information, a provisional diagnosis is appropriate. Otherwise, describe the presentation and note that assessment is ongoing.