Complete a Psychotherapy Intake Note

TherapyNotes’ Psychotherapy Intake Note allows you to document a full biopsychosocial evaluation of your client, including the presenting problem, a mental status exam, and history. It also allows you to document other important events that occur during the intake process, such as obtaining informed consent for treatment, reviewing practice policies and procedures, and discussing important topics like confidentiality and billing. 

To make documenting the client history even easier, you can send a Client History Form ahead of time and use the History button to pull client responses directly into your note. You can document direct quotes (such as in the Presenting Problem) or edit and add your clinical impressions and other information gathered in session.

A Psychotherapy Intake Note is connected to an appointment when Therapy Intake is selected as the Appointment Type. Once a scheduled Therapy Intake begins, TherapyNotes will generate a To-Do list item prompting the clinician to create the corresponding Intake Note. To learn more about creating notes and note writing tools in TherapyNotes, read Create a Note.

Role Required: Clinician, Intern, or Clinical Administrator

Note Header

The note header automatically populates information for the clinician, client, and appointment, including relevant supervision information, client insurance, and service code. To edit information in the note header such as the Note Title or Service Code or to add information such as add-on codes, click anywhere on the note header or click Edit in the upper right corner. You can also document who participated the session, such as when working with collateral contacts or family members.

Presenting Problem

This is the client’s description of why they are seeking treatment. Typically, a direct quote from the client is included in this field along with the clinician’s impression of the issue. Often information about duration, intensity, frequency of treatment, and precipitating factors are included as well. This field is required for a complete Intake Note.

Current Mental Status

Intake Notes contain a full Current Mental Status exam. Use our one-click autofill options (All Normal or All Not Assessed) to simultaneously fill each of the fields, click in each field to select from a list of common responses, or enter your own information.

Risk Assessment

Select the checkbox to indicate that the client denied all areas of risk and that your clinical assessment did not find any contrary indications. If your client does present with an area of risk, click in the field to select from a list of common areas of risk or type your own. Next, select the appropriate level of risk and indicate if the client has intent, plans, and means to act. These fields are all required for each area of risk documented.  

Optionally, you can add risk and protective factor information and additional details  Click in the appropriate field, then select as many options from the list as apply or enter your own factors. If your client presents with more than one area of risk, use the +Add Area of Risk link at the bottom to add another set of fields to document each area separately. Use the arrows in the top right of the section to order the areas of risk in your note, or click the “X” to remove an area of risk entirely.

Objective Content

This section allows you to document all the activity of the intake session outside of history-taking. You can provide details about client presentation and your informed consent process. You can also document reviewing important policies and procedures, such as limits to confidentiality, cancellation and billing policies, and communication between sessions. 

Biopsychosocial Assessment

This is where you can document your client’s relevant history. Placeholder text in each field prompts for what type of information you may want to include in that area. The History button at the top allows you to pull information from the Client History Form or prior Psychotherapy Intake notes into all fields simultaneously or use the button next to each field to select one at a time. The Other Important Information field allows you to readily document additional information that impacts treatment which may not be represented in other fields above. This may include information specific to your modality of practice or requirements from licensing boards or insurance payers.

Plan

This field is where you can document the next steps in the treatment process. That may include additional assessment, coordinating care with primary physicians or other providers, requesting additional records, or developing a full treatment plan.

Diagnosis

The Diagnosis section will automatically populate a DSM-5 diagnosis code and description based on the information entered in the client's Treatment Plan or most recent note. These fields also feature searchable DSM-5 diagnoses, allowing you to easily edit existing or add additional diagnoses.

Sign and Save

Once you have completed your Intake Note for the session, select the  Sign this Form checkbox to electronically sign the note and click the Create Note button.  Electronic signatures are captured in accordance with appropriate requirements.  Multiple factor authentication is required to identify the user signing the note. The application automatically captures the timestamp for the signature as well. Electronic signatures cannot be edited or modified.  

If the document is placed in draft mode and then re-signed, the signature on the note will reflect the most recent electronic signature captured. You can view other signatures, including the timestamp of the first signature on the note, using the Note Revision History.  All actions related to note signatures are captured in the activity log for the practice.

Note: In order to save a Psychotherapy Intake Note, you must enter the  Presenting Problem, Risk Assessment, and Diagnosis. All other fields are optional.

To save an unfinished Intake Note, leave Sign this Form unchecked and click the  Save Draft button. You may access your draft Progress Note later from your To-Do list or click Patients > Patient Name > Documents tab.

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