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.

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