Intake & assessment

Intake Assessment

First-session biopsychosocial assessment covering history, presenting problem, risk and initial diagnosis.

Supports:IndividualCouplesFamily7 sections

What it is

The intake assessment gathers the full biopsychosocial picture at the start of care: why the client is here, history, psychosocial context, a mental status exam, risk, a provisional diagnosis and initial recommendations.

When to use it

First sessions and re-intakes
Establishing the diagnosis that later notes will reference
Laying groundwork for the treatment plan

Sections

What Tidemend writes in each section. You can rename, reorder or adjust any of these in a custom template.

Presenting Problem
Reason for seeking care in the client's words, onset, duration and severity.
History of Present Concern
Course of symptoms, precipitating events, previous treatment.
Psychosocial History
Family, relationships, education/work, culture, substance use, legal and medical history as discussed.
Mental Status Exam
Appearance, behavior, speech, mood, affect, thought process and content, cognition, insight, judgment.
Risk Assessment
Document screening for suicidal ideation, homicidal ideation and self-harm. State denials explicitly if the client denied risk. Note protective factors and any safety planning.
Diagnostic Impression
Provisional diagnosis with ICD-10 code(s) and rationale.
Initial Treatment Recommendations
Recommended modality, frequency, goals to develop and referrals.

Example Intake Assessment

Individual · 60 min · Intake · fictional example

Presenting Problem

Client seeks care for worry that “never switches off,” present for about a year and worse over the past three months, affecting sleep and concentration at work.

History of Present Concern

Worry intensified after a promotion with increased responsibility. Client tried a meditation app with limited benefit. No prior mental health treatment.

Psychosocial History

Lives with a partner; close to one sibling. Works full time in an office role. Drinks alcohol socially, one to two drinks a week. No legal concerns. Medical history unremarkable per client report.

Mental Status Exam

Alert, oriented and cooperative. Speech normal. Mood “wound up”; affect anxious, full range. Thought process goal-directed; content focused on work worries. No perceptual disturbances. Insight and judgment good.

Risk Assessment

Denied current or past suicidal ideation, self-harm or homicidal ideation. Protective factors: partner, employment, future orientation.

Diagnostic Impression

F41.1 Generalized anxiety disorder (provisional), based on excessive worry most days for over six months with sleep disturbance and impaired concentration.

Initial Treatment Recommendations

Recommend weekly CBT for anxiety. Develop treatment plan with goals for worry reduction and sleep next session. Administer GAD-7 at baseline.

Fictional example written for illustration. It doesn’t describe a real person or session.

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