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A therapy intake note documents a new client's first clinical session: presenting problem, relevant history, a risk screen, mental status observations, an initial clinical impression, and the starting plan. Therapists, counselors, and psychologists write one at the start of each new episode of care, and the rest of the chart builds on it. A typical intake note runs 300 to 900 words.
Therapists, counselors, psychologists, clinical social workers
Downstream treating team, supervisors, payers, auditors
300 to 900 words · 20 to 40 minutes by hand (clinical team estimate)
Intake and assessment documentation (compare: biopsychosocial assessment, psychiatric diagnostic evaluation)
At the first session with a new client, or at the start of a new episode of care
No US, Canadian, or Australian law prescribes an intake form; rules attach to the record, facility, billed service, and payer
An intake note is the record of a client's first clinical session: why the person is seeking care, the history that bears on treatment, a risk screen, early observations, and the starting plan. Clinicians also call it an initial assessment, intake assessment, or initial evaluation. No single author or standards body created the format. It descends from the case-history tradition, with roots in Mary Richmond's 1917 Social Diagnosis, Lawrence Weed's 1968 problem-oriented medical record, and George Engel's 1977 biopsychosocial model, and every practice adapts it. No US, Canadian, or Australian rule prescribes a document called an intake note: requirements attach to the clinical record, the facility type, the billed service, and the payer program instead.
Two boundaries matter more than the rest. First, the intake note is a document, while the psychiatric diagnostic evaluation (90791 or 90792) is a billable service: Medicare contractor policy describes that service as a biopsychosocial assessment, so when the first session is billed as one, the intake note is the record that has to support it. Second, an intake note is part of the standard clinical record, not a HIPAA psychotherapy note: the special protected category expressly excludes diagnosis, symptoms, functional status, treatment plans, prognosis, and progress, which is most of what an intake note contains. Write it knowing the client, other providers, and payers can read it.
Every setting that accepts new clients writes intake documentation: private and group practices, community mental health centers, university counseling services, employee assistance programs, and telehealth practices. The intake note starts the episode of care, and its readers are often downstream: the clinician a client transfers to, the supervisor reviewing a pre-licensed clinician's work, the payer reviewing medical necessity, or you, a year later. After intake, ongoing sessions move to a progress note format and the treatment direction lives in the treatment plan. Specialized concerns get their own deeper workups, such as a trauma assessment, and agencies that need the full biological, psychological, and social picture use the longer biopsychosocial assessment.
Identifying information and referral. Client identifiers, date, clinician, referral source, service type, and start and stop times, together in one header block. Pitfall: scattering these details through the narrative; reviewers and records staff need them findable in seconds.
Presenting problem. Why the client is here now, in their own words, plus onset, duration, severity, and what prompted the contact. Pitfall: recording only your clinical rephrasing; a short quote preserves the client's frame and anchors medical necessity.
Relevant history. Psychiatric history and prior treatment, medical conditions and current medications, and family psychiatric history. Pitfall: writing "noncontributory" without asking; to an auditor it reads as not assessed.
Social context. Living situation, relationships, work or school, legal involvement, and cultural or identity factors the client raises. Pitfall: overcollecting sensitive detail with no clinical use; everything here is part of the accessible record.
Substance use. Current and past use, substances, frequency, and most recent use. Pitfall: skipping the screen because the presenting problem seems unrelated; intake is exactly where screening is expected.
Risk screen. Current and historical suicidal ideation, self-harm, and thoughts of harming others, protective factors, and any action taken. Pitfall: leaving risk blank when findings are negative; write the negative finding so the record shows you asked.
Mental status observations. A brief mental status exam: appearance, behavior, speech, mood, affect, thought process, insight, judgment. Pitfall: template MSE strings that contradict the narrative, such as "euthymic mood" above a tearful presentation.
Initial impression and plan. Provisional diagnosis with rule-outs, initial goals, recommended modality and frequency, referrals, consent confirmation, and the next appointment. Pitfall: an impression that floats free; every diagnosis needs supporting symptoms documented above it.
Client: [initials] DOB/Age: Date: Clinician: Referral source: Service: [intake / initial assessment] Start/stop time: PRESENTING PROBLEM In the client's words: Onset / duration / severity / precipitant: HISTORY Psychiatric (prior treatment, hospitalizations): Medical conditions + current medications: Family psychiatric history: SOCIAL CONTEXT (living, relationships, work/school, legal, cultural): SUBSTANCE USE (substances, frequency, last use): RISK SCREEN SI / self-harm / harm to others (current + history): Protective factors / action taken: MENTAL STATUS (appearance, speech, mood, affect, thought process, insight): STRENGTHS & SUPPORTS: MEASURES (e.g., PHQ-9, GAD-7 + scores): INITIAL IMPRESSION (provisional dx + rule-outs): INITIAL PLAN (goals, modality, frequency, referrals, next appt): Consent for treatment reviewed and signed: [Y/N] Clinician signature/credentials: Date signed:
Free to use and share, no signup. The PDF includes a one-page cheat sheet with section-by-section pitfalls and a pre-sign checklist; the DOCX is the blank template, ready to adapt.
Scenario: adult client, self-referred for anxiety and sleep problems after a job change, first session in an outpatient private practice. All details are fictional.
Client: R.L., 32 · Date: 07/09/2026 · Clinician: A. Morgan, LPC · Service: Intake / initial assessment, 58 min, in office · Referral: Self · Start/stop: 14:02 to 15:00
Presenting problem: Client sought care for "worry I can't switch off since the promotion," describing four months of escalating anxiety after moving into a supervisory role in March. Reports taking 60 to 90 minutes to fall asleep most nights, Sunday-evening dread, irritability at home, and two episodes of racing heart and shortness of breath during meetings, each resolving within minutes. Wants "tools to turn work off and be present with my family."
History: No prior psychotherapy or psychiatric hospitalization; brief school counseling at 16 after parents' divorce. No psychiatric medications, current or past. Medical: unremarkable PCP visit January 2026 per client report; no current medications except occasional ibuprofen. Family history: mother treated for depression in her 40s, per client report.
Social context: Lives with spouse and 4-year-old daughter; describes the marriage as supportive though "tense lately because I bring work home." Operations supervisor with 14 direct reports since March; denies legal involvement. Running was a primary coping outlet and has lapsed since the promotion.
Substance use: Alcohol 2 to 3 drinks per week, unchanged in the past year; denies tobacco, cannabis, and other drug use; denies any history of problem use. Caffeine: 2 coffees daily.
Risk screen: Denies current suicidal ideation, intent, or plan; denies history of suicidal behavior or self-harm; denies thoughts of harming others. Protective factors: engaged parenting role, supportive spouse, future orientation, help-seeking. No risk indicators observed in session. Routine monitoring is appropriate; no safety plan indicated at this time.
Mental status: On time, groomed, cooperative. Speech normal in rate and volume. Mood "keyed up"; affect anxious, full range, congruent. Thought process linear and goal-directed. No perceptual disturbance reported or observed. Insight and judgment good.
Measures: GAD-7 = 12 (moderate). PHQ-9 = 6 (mild); item 9 not endorsed.
Strengths and supports: Motivated and specific about goals, stable employment, supportive family, prior success using structure and exercise as coping.
Initial impression: Adjustment disorder with anxiety (F43.22), provisional; rule out generalized anxiety disorder given the four-month course and physical symptoms. Symptoms cause clinically significant distress and functional impact at work and home.
Initial plan: Weekly individual CBT, 50-minute sessions, initial course of 8 to 12 sessions. Session 2: build the collaborative treatment plan with measurable goals. Begin a sleep log and scheduled worry time this week. Client will schedule a PCP follow-up to rule out medical contributors to the episodic palpitations. Re-administer GAD-7 and PHQ-9 at session 4. Limits of confidentiality, fees, and practice policies reviewed; informed consent signed and filed. Next appointment 07/16/2026.
This sample is fictional and for educational purposes. It does not describe a real patient.
Writing these after every session? BastionGPT drafts complete notes from bullets, dictation, or a transcript.
Generate a note from bulletsAn intake note is part of the designated record set: the client can request it, payers can audit it, and every later note builds on it. Keep private process reflections out of it; they belong in segregated psychotherapy notes with their own authorization rules. Two Ontario rules answer questions clinicians everywhere ask. A client cannot condition consent on keeping professionally required information out of the chart: Ontario's health privacy law makes such a condition ineffective where it "purports to prohibit or restrict any recording" required by law or established professional practice (PHIPA s. 19(2)). And rough interview jottings do not have to become part of the record: Ontario's psychotherapy college permits destroying rough notes the same day, provided they are used to complete the formal record first. Treat both as the shape of the rule and check your own jurisdiction.
For a billed intake in the US, the medical-necessity chain starts here. Medicare contractor policy treats the diagnostic evaluation as a biopsychosocial assessment, and its documentation expectations reach the note: patient identification on every page, the legible signature of the clinician responsible for the care, and support for medical necessity. Frequency is contractor policy, not a single national rule. The same Novitas policy allows another evaluation for a new episode of illness, a readmission due to complications, or a new referral question, recognizes that children and geriatric patients may need more than one visit, and caps coverage at three evaluations per year, per beneficiary, by the same provider. The famous 24-hour intake deadline is also narrower than most template pages suggest: 42 CFR 485.914 gives Medicare-certified community mental health centers 24 hours for the initial evaluation and 4 working days for the comprehensive assessment; an ordinary private practice does not inherit those deadlines.
In Australia, Better Access turns on a different document entirely: after each course of treatment the therapist must send the referrer a written report covering assessments, treatment, and recommendations, and a verbal report does not qualify for Medicare payment. Wherever you practice, the intake note feeds the treatment plan and sets the baseline that progress notes move against, so record baselines you intend to measure.
The audit record for intake documentation is largely the audit record for the services it supports. In Medicare's 2024 reporting-period data for outpatient psychiatry, the improper-payment rate was 16.1%, a projected $254.5 million, and insufficient documentation drove 78.3% of it, with another 17% having no documentation at all. A national OIG psychotherapy audit estimated $580 million improperly paid, with signatures missing on 31 of 216 sampled days. The same audit also rebuts one-size-fits-all advice: 35 sampled days had no treatment plan and were still allowable, because only three of the seven Medicare contractors involved required one. The BastionGPT Clinical Advisory Board sees the same errors most often in intake note reviews:
| Aspect | United States | Canada | Australia |
|---|---|---|---|
| Status | No federal intake form; content rules attach to facility type (the 24-hour rule is specific to Medicare-certified CMHCs) and to Medicare contractor policy | Provincial college standards prescribe record contents (Ontario CRPO client profile, CPBAO record requirements, Quebec's psychologist regulation) | Psychology Board Code of Conduct (December 2025) makes records mandatory but expressly leaves form and content to the service and setting |
| Terminology | Intake note, initial assessment, psychiatric diagnostic evaluation | Client profile, initial assessment, clinical record | Initial consultation, client records; Better Access adds the referrer's treatment plan and the therapist's course report |
| What changes | Payer and contractor documentation fields, medical-necessity support, authentication rules | College-prescribed record contents and provincial privacy law (PHIPA and analogues) | MBS referral and reporting chain, course caps, program eligibility |
| Retention | State law, not HIPAA: California 7 years after termination, New York at least 6 years, minors longer in both | Province and college: Quebec 5 years, Ontario 10 years, British Columbia 16 years, each running from last contact or adulthood | 7 years from the last entry for adults; until the 25th birthday for clients under 18 (Board code) |
The intake note itself travels well across all three countries; the rules around it do not. Content requirements come from your college, contractor, or program, and retention runs from the end of care or adulthood, not from the intake date.
BastionGPT is specifically trained, tuned, and clinically tested on intake notes.
See how clinicians use it day to day on the AI therapy notes page.
Many BastionGPT users report saving more than 90 minutes per day on documentation.
HIPAA-compliant with a signed BAA on every plan. Your data is never used to train models. BastionGPT drafts, you review and sign.
Most intake notes run 300 to 900 words and take 20 to 40 minutes by hand, longer than a progress note because they carry history and the baseline risk screen. No regulation in the US, Canada, or Australia sets a word count or a required intake format; length should come from what the note must support: continuity, safety decisions, and medical necessity, without irrelevant or stigmatizing detail.
The intake note is the baseline: history, risk screen, initial impression, and starting plan, written once per episode of care. A progress note documents one session's work and what changed against that baseline. Progress notes should not keep reproducing the intake history; they move the story forward.
A biopsychosocial assessment is a content framework covering biological, psychological, and social domains. It can be the intake note, an attached structured assessment, or a separate, longer document; no rule requires them to be separate. Agencies and higher-acuity settings tend to use the fuller standalone version, while private practices often fold the domains into a leaner intake note.
No. HIPAA's psychotherapy-notes category expressly excludes diagnosis, symptoms, functional status, the treatment plan, prognosis, and progress, which is most of what an intake note contains. The intake note is part of the standard record and the designated record set, and labeling it a psychotherapy note does not change that. True psychotherapy notes must be kept separate and have their own authorization rules.
90791 and 90792 describe a service, the psychiatric diagnostic evaluation, and Medicare contractor policy describes it as a biopsychosocial assessment. When that service is actually performed at the first session, the intake note is the record that supports it. Frequency is contractor policy rather than one national rule: Novitas policy, for example, allows another evaluation for a new episode, a readmission with complications, or a new referral question, recognizes that children and geriatric patients may need more than one visit, and caps coverage at three per year per beneficiary by the same provider. Check your own MAC and payer contract.
There is no universal deadline. The often-quoted 24-hour rule belongs to Medicare-certified community mental health centers, where 42 CFR 485.914 requires an initial evaluation within 24 hours of admission and a comprehensive assessment within 4 working days; private practices do not inherit it. Australia's Psychology Board code says records are made at the time of events or as soon as possible afterward, and every jurisdiction expects timely, dated authentication.
There is no blanket rule. Ontario's psychology college has a targeted version: documents containing conclusions, judgments, decisions, diagnoses, or recommendations need the responsible registrant's signature, and both sign when the author is not authorized for autonomous practice. US Medicare requires a supervising signature where the billing or supervision arrangement calls for one. What governs is your licensing board, the payer's rules, the facility policy, and the written supervision agreement.
HIPAA sets no chart-retention period; state law governs in the US. California requires 7 years after therapy terminates, and New York at least 6 years, with longer periods for minors in both. Canada varies by more than threefold: Quebec psychologists 5 years, Ontario 10 years, British Columbia 16 years. Australia's Board code requires 7 years from the last entry, or until the 25th birthday for clients under 18. All of these run from the end of care or adulthood, not from the intake date.
Yes. Paste a first-session transcript, dictate, or give it bullets, and it produces a structured intake note draft for your review, including the sections payers expect. It can also summarize a referral packet into the history sections. BastionGPT is HIPAA-compliant with a signed BAA on every plan, and your data is never used to train models.
The compliance claims on this page trace to these authorities, last verified July 2026:
Educational content, not legal or billing advice. Sample notes are fictional. Follow your organization's policies and your board, payer, and jurisdiction requirements.