The Intake Note Template

The Intake Note Template — a fillable biopsychosocial intake for your first-session workflow

You know the note is going to take an hour no matter what. The client's story is fresh, the risk section needs to be airtight, and somewhere in the back of your mind is the reviewer who might pull this file in eighteen months. This template is built for that exact moment: it turns a blank page into a guided, section-by-section intake you can complete faster, with language that holds up if anyone ever asks you to defend it.

What's inside (16 pages):

• Part One — The Intake Note (pages 3–10): a fillable biopsychosocial intake covering identifying information and presenting problem, psychiatric/medical/family/developmental history, substance use and trauma history, a full risk assessment (SI/HI/self-harm), mental status exam, diagnostic impression and clinical formulation, and initial recommendations with a medical necessity statement.
• Part Two — The Phrase Bank (pages 11–15): copy-paste clinical language organized by section — presenting problem, risk, mental status exam, diagnosis and medical necessity — so you're never staring at a blank box trying to find the right words.
• Documentation checklist (page 15): a two-minute pass to run before you close the note, so nothing gets missed.

Why clinicians reach for it:

Every risk section is built so you document thoroughly even when the client denies everything — because "denies SI, HI, and self-harm" still needs to be on the page. The diagnostic section pushes you to tie symptoms to criteria to functional impairment to treatment, so the medical necessity is explicit instead of implied. And because it's fillable, you can type directly into it on a laptop between sessions or print it for paper charts.

Written by Carol Galloway, LMHC, for licensed clinicians and trainees under qualified supervision.

Fillable PDF · Instant Download · 16 pages · Insurance-ready language

Not legal, billing, or coding advice.

$15