Intake Form Template for Mental Health Assessment

In the video above on Intake Form Template you will take away:

  • The important parts and pieces of a sample intake form assessment
  • Learn how a robust intake form gets counseling started off right
  • Discover where you can download an intake form assessment immediately

This sample Intake Form Template is a two page form :

The first line item on page 1 is “Client’s stated purpose for counseling.” Here you will briefly state the reason the client gave you when you asked the question, “What brought you here today?”

There are 11 specific areas of clinical concern plus space for writing in “other”.
Page 1 is the place where you can summarize your findings from the biospychosocial (Which incidentally is a comprehensive 5 page tool that dovetails seamlessly with this Intake Assessment Form… both are included in the Intake Forms Tool Kit)

Page 1 is like a snapshot of all the areas of clinical concern. This is the kind of concise information you will need about your client to begin making an accurate diagnosis and creating an appropriate treatment plan.

Take Away Tip: The intake assessment consists of 2 broad sets of data:

  1. Page one which focuses mainly on the historical information reported to you by the client.
  2. Page 2 has to do with your professional clinical impressions based on the client history and your professional analysis and observation.

On page 2 of the Intake Form Template there are 3 sections:

Clinical Observations:
This is essentially the mental status exam where the therapist assess mood/affect, behavior, cognitions etc.

Clinical Impressions:

This is where the therapist writes out their own statement about how the client presented. Include those things that are of clinical concern and relate direct to client’s presenting problem and reason for counseling.

Take away tip: Always do your best to write in measurable and observable terms, avoiding stereotypes and opinionated statements. Keep it concise and to the point. You are creating a professional picture/snapshot of how the client appeared upon intake.

Diagnostic Impressions

This Intake form assumes you will be using the DSM V diagnostic criteria, plus it includes a space to record defense mechanisms.

Not all therapists make note of defense mechanisms but I have found it helpful for myself and the client to identify those, since they can play such an important role in the client’s recovery.

Here’s a couple questions to consider: “How will the diagnosis help the client” to reach their goals. Is assigning a diagnosis in the best interest of the client.

The Intake Forms Tool Kit contains an alternative Intake Form which does not use the DSM diagnostic criteria.

On the “non DSM” form it simply asks for you to identify the “primary problem” and also note whether there are substance issues, health issues and psychosocial stressors. As well as a prompt for identifying primary defense mechanisms.

Take Away Tip: Helping the client to identify and utilize healthy defense mechanisms can have a very significant and positive impact on therapeutic outcome.

In Summary, the intake form has 2 main categories of information:
1. The client history
2. The therapist’s clinical observations and impressions

A robust form like this one will assist the counselor in conducting a thorough and effective intake that will help identify the primary areas of concern and begin to formulate the treatment plan goals and objectives.

For more information on downloading this intake form assessment as well as other tools and forms to make your job easier go to or click the link in the description below this video.

For more Counseling Forms tips subscribe to my Counseling Forms YouTube Channel

NOTE: In the video I state this Intake Form Assessment is available in the Private Practice Starter Kit. It is also included in the Intake Forms Tool Kit.


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