Monthly Archives: February 2012

Intake Assessment Form

The Intake Assessment Form is the form mental health counselors use to create their clinical report for the client’s record that documents the following:

  • Areas of clinical concern
  • Clinical observations
  • Clinical impressions
  • Preliminary diagnostic impressions

The intake assessment form that is included in our Intake Forms Tool Kit and Private Practice Starter Kit can be downloaded immediately. All forms are created in Microsoft Word. It includes all of the above categories as described in further detail below.

Areas for clinical concern may include documentation in the following categories:

  • Mental health, abuse, addictions, developmental, social, educational, occupational, legal, family etc.
  • Our form includes 13 clinically relevant categories and space for indicating other concerns.

Areas for clinical observation include documentation in the following categories:

  • Appearance, speech, mood/affect, behavior and cognition
  • Our intake assessment form includes check lists of symptoms in each of the above categories

Areas for clinical impression include space to:

  • Write in statement on clinical impressions
  • Document by checking criteria for judgment/insight and orientation

Area for diagnostic impressions include space for documenting:

  • Primary diagnosis as focus of treatment
  • Personality factors
  • Medical factors
  • Psychosocial factors
  • Primary defense mechanisms

The Intake Assessment Form is a vital tool in a counselor’s toolkit. This is a 2 page form. The first page is where you create a summary of the clinical areas for concern. The second page presents the areas for clinical observation, impressions and diagnoses. In addition to the Intake Assessment there are 5 additional forms in the Intake Forms for Counselor’s Kit. For more information about our Intake Forms Tool Kit or Private Practice Starter Kit or to purchase go here.

Sample Intake Forms

Intake Forms for Mental Health Counselors

Sample intake forms for mental health counseling can be created yourself in Microsoft word. However for the amount of time spent, it is typically easier to purchase a set of downloadable forms for a reasonable price, save them to your own computer and simply add your own letterhead in the heading. In a matter of minutes you can have your own set of professional forms.

However if you choose to create your own sample intake forms here are some things to consider: First you will need a comprehensive biopsychosocial. This form is a must to conduct a thorough client intake interview from which the counselor will then write their Intake Assessment which includes the mental status report and diagnosis.

We recommend that you use check boxes where appropriate as this will provide you with more comprehensive information. For example your biopsychosocial intake forms should include a list of symptoms that would help you to make an appropriate diagnosis…such as:

  • Obsessive thoughts
  • Depression
  • Sleep disturbance
  • Appetite changes
  • Anxiety and worry
  • Spiritual or faith difficulties
  • Grief/loss
  • Relationships
  • Anger

Our comprehensive biopsychosocial has a check list of 44 symptoms, for past, present and never experienced.

Other categories you will want to include on your sample intake form would be:

  • Previous mental health history, especially suicidal/homicidal tendencies
  • Health history and whether they are on any medications
  • Legal history – lawsuit involvement or criminal convictions
  • Educational history – including strengths, weaknesses and learning styles
  • Abuse history – as a victim or perpetrator
  • Addictions – including things like street or Rx drugs,food, sex and pornography
  • Sexual history – especially any sexual difficulties client is struggling with
  • Health and nutrition –  Often overlooked information that can affect mental health
  • Goals for counseling – what does your client want from your time together

Our Intake Forms for Counseling Kit includes a comprehensive biopsychosocial with a 44 symptom checklist plus 16 categories of information that dovetail with the Intake Assessment form, plus Personal Information and Insurance, Information and Consent, Release of Information for a total of 5 forms.