Therapy Intake Note and Biopsychosocial Assessment Template (With Example)

A therapy intake note is more than a first impression. It is the document that justifies the initial evaluation, establishes medical necessity, and gives every later note a place to stand. A strong intake note combines a presenting problem, a history of present illness, psychiatric and medical history, family and developmental history, social and cultural context, substance use, a mental status exam, an explicit risk assessment, an initial diagnostic impression, and a bridge to the treatment plan.

This article gives you a copy-ready intake note and biopsychosocial assessment template, a full realistic example, and the common audit mistakes that get 90791 claims pushed back.

What a first-session intake note must capture

Payers and licensing boards look for the same basic facts. If any of these are missing, the record looks incomplete under review:

• Identifying information. Name, date of birth, contact details, emergency contact, and how the client was referred.
• Presenting problem and HPI. Why the client came now, in their own words, with onset, duration, severity, and what has or has not helped.
• Psychiatric history. Prior diagnoses, hospitalizations, therapy, medications, and outcomes.
• Medical history. Conditions, medications, and any medical issues that affect mental health.
• Substance use. Current and past use of alcohol, cannabis, prescription medications used outside medical direction, and other substances.
• Family history. Mental health, substance use, and suicide history in first-degree relatives.
• Developmental and social history. Childhood, education, relationships, work, culture, spirituality, and current living situation.
• Mental status exam. Appearance, behavior, mood, affect, speech, thought process and content, cognition, insight, and judgment.
• Risk assessment. Explicit statement of suicidal ideation, intent, plan, access to means, self-harm, and violence risk, plus protective factors and actions taken.
• Initial diagnostic impression. Provisional DSM-5-TR or ICD-10 codes with reasoning.
• Initial treatment plan bridge. Goals, proposed frequency, modalities, and any referrals or coordination.

Biopsychosocial intake note template

Use this as a starting point and adjust it to your jurisdiction, payer, and modality.

THERAPY INTAKE NOTE / BIOPSYCHOSOCIAL ASSESSMENT

Client name/ID: [ ]
Date of birth: [ ]
Date of intake: [ ]
Session type: [in person / telehealth / phone]
Referral source: [ ]
Emergency contact: [ ]

PRESENTING PROBLEM / HISTORY OF PRESENT ILLNESS
Client reports: [quote or paraphrase in client's words]
Onset: [ ]
Duration: [ ]
Severity: [ ]
Precipitating stressors: [ ]
Prior attempts to address concern: [ ]

PSYCHIATRIC HISTORY
Prior diagnoses: [ ]
Prior therapy/counseling: [ ]
Prior psychiatric hospitalizations: [ ]
Current psychiatric medications: [ ]
Prior psychiatric medications and response: [ ]

MEDICAL HISTORY
Current medical conditions: [ ]
Current medications: [ ]
Relevant medical history: [ ]
Allergies: [ ]

SUBSTANCE USE HISTORY
Alcohol: [ ]
Cannabis: [ ]
Prescription medications used outside medical direction: [ ]
Other substances: [ ]
Past treatment for substance use: [ ]

FAMILY HISTORY
Mental health conditions in first-degree relatives: [ ]
Substance use history: [ ]
Suicide or self-harm history: [ ]

DEVELOPMENTAL AND SOCIAL HISTORY
Developmental milestones: [ ]
Education: [ ]
Occupation/financial: [ ]
Relationships and supports: [ ]
Cultural/spiritual factors: [ ]
Current living situation: [ ]
History of trauma or abuse: [ ]

MENTAL STATUS EXAM
Appearance: [ ]
Behavior/psychomotor: [ ]
Mood: [ ]
Affect: [ ]
Speech: [ ]
Thought process: [ ]
Thought content: [ ]
Perception: [ ]
Cognition/orientation: [ ]
Insight: [ ]
Judgment: [ ]

RISK ASSESSMENT
Suicidal ideation: [none / passive / active]
Intent: [none / present]
Plan: [none / present, describe]
Access to means: [none / present, describe]
Self-harm: [none / history / current]
Violence risk: [none / elevated, explain]
Protective factors: [ ]
Actions taken: [ ]

INITIAL DIAGNOSTIC IMPRESSION
Provisional diagnosis: [DSM-5-TR code and name]
Justification: [summary of symptoms and functional impact]
Rule-outs: [ ]

TREATMENT PLAN BRIDGE
Proposed goals: [ ]
Recommended frequency: [ ]
Modality: [ ]
Referrals or coordination: [ ]
Client consent and understanding: [ ]

Clinician signature, credentials, date: [ ]

Full clinical example

Client: Lena Voss, 29, referred by her primary care physician after a panic attack at work.

Presenting problem: Lena reports three months of escalating worry about work performance, sleep disruption, muscle tension, and two full panic episodes in the past month. She says, "I keep imagining my manager calling me in and telling me I have failed." Symptoms worsen on Sunday evenings. She has avoided two work social events.

Psychiatric history: Brief counseling at university after a breakup at age 21. No prior psychiatric medications. No hospitalizations.

Medical history: Hypothyroidism, stable on levothyroxine. No other conditions.

Substance use: One to two glasses of wine on weekends. Occasional cannabis use in the past, none in the last year. No tobacco or other substances.

Family history: Mother has generalized anxiety disorder. Maternal uncle died by suicide in his thirties.

Developmental and social history: Grew up in a high-achievement household. Completed a master's degree. Works as a data analyst. Lives with a partner. No children. Reports stable relationship but feels she "hides the worst of it." No history of physical or sexual abuse.

Mental status exam: Lena is well-groomed and cooperative. Psychomotor activity is slightly restless. Mood is anxious. Affect is constricted but appropriate. Speech is rapid at times but coherent. Thought process is goal-directed. Thought content includes catastrophic predictions about work failure; no delusions or hallucinations. Cognition is intact. Insight and judgment are good.

Risk assessment: Lena denies current suicidal ideation, intent, or plan. Denies self-harm urges. Denies thoughts of harming others. Protective factors include stable relationship, employment, and motivation for treatment. No immediate safety concerns. Safety planning discussed; client agrees to contact the office if risk escalates.

Initial diagnostic impression: F41.1 Generalized Anxiety Disorder, provisional. F43.23 Adjustment Disorder with Anxiety as a rule-out. Symptoms meet criteria for excessive worry, difficulty controlling worry, and functional impairment in sleep and social participation.

Treatment plan bridge: Goal 1: reduce frequency of catastrophic work worry to no more than twice weekly. Goal 2: restore consistent sleep. Begin weekly CBT sessions. Introduce thought records and relaxation skills. Coordinate with primary care physician regarding thyroid levels. Client provided informed consent.

Common audit mistakes on intake notes

Insurance reviewers commonly deny or request more information for 90791 initial evaluation codes when the note is missing one of these:

• A clear history of present illness. "Client is anxious" is not enough. Document onset, duration, severity, and functional impact.
• Medical necessity. Show why psychotherapy is needed now and why the level of care is appropriate.
• A mental status exam. Even a brief, structured exam helps justify the evaluation.
• An explicit risk assessment. Silence on risk can trigger a records request. State what was asked and what was found.
• A diagnosis tied to symptoms. The diagnostic impression should reference specific criteria and functional impairment.
• Signature and credentials. The note must be signed by the qualified clinician who performed the evaluation.

How Citt.ai drafts intake notes and compiles the initial client picture

Citt.ai listens to the intake session and drafts a biopsychosocial intake note in the structure your practice uses. The draft preserves exact client language around risk, symptoms, and history, and it surfaces those sections for your review before you approve the note.

Once approved, the intake note becomes the foundation of the compiled client picture. Later progress notes, assessment scores, check-ins, and risk signals are added to the same timeline, so every future session starts with the context you gathered in the first meeting.