The short answer
A complete intake covers the reason for referral, current symptoms, psychiatric, medical, substance use, family and social history, a mental status exam, a risk assessment, rating scales, a diagnostic impression, and a plan with the recommended level of care.
Intake assessment checklist
- Identifying information and reason for referral, in the client's words.
- History of the present illness: onset, duration, severity, triggers and what has helped.
- Psychiatric history: diagnoses, hospitalizations, past treatment and medication trials.
- Medical history, current medications and allergies.
- Substance use, including screening with a tool like the AUDIT.
- Trauma history, asked with care.
- Family psychiatric history.
- Social history: living situation, relationships, school or work, legal and cultural factors.
- Mental status exam.
- Risk assessment: suicide, self-harm, harm to others, and safety planning when indicated.
- Rating scales, such as the PHQ-9 and GAD-7.
- Diagnostic impression, recommendations and level of care.
Red flags not to miss
- Suicidal thoughts, plans, intent or access to lethal means.
- Thoughts of harming others.
- Possible abuse or neglect that may require a mandated report.
- Signs of withdrawal, delirium or a medical problem that needs urgent care.
- Psychosis or mania that may need a higher level of care.
Writing the intake note
Summarize the findings in a clear narrative that supports the diagnosis and the plan. Payers and future providers read the intake to understand medical necessity, so connect symptoms and impairment to the recommended services.
Frequently asked questions
How long does a psychiatric intake take?
Often 60 to 90 minutes, depending on complexity and whether caregivers or records are involved.
What rating scales are used at intake?
Common ones include the PHQ-9 for depression, the GAD-7 for anxiety, the PC-PTSD-5 or PCL-5 for trauma and the AUDIT for alcohol use.
Related resources
From JV Clinical Technologies, founded by Jaime Varney, PMHNP-BC. General professional education only, not legal, billing or clinical advice for a specific case. Check current payer, state and professional rules before relying on any requirement described here.