Counseling intake summary example For counseling, it is typical to use intake forms that gather the following information: personal details, emergency contact information, employer information, medical history, and information regarding why the patient is seeking counseling treatment. A treatment plan establishes objectives and monitors progress. After a patient completes the intake form, it is common to have an intake session. Counseling and Therapy Intake Form Templates and Examples Updated: December 26, 2024 General Therapy Intake Form Example – Name: John Doe – Address: 123 Main St, Anytown, USA – Phone Number: (555) 123-4567 – Email: johndoe@example. Understanding coping styles, setting goals, identifying negative thoughts, exploring character strengths, and managing Caregiver Intake Report (Clinician) Date of Examination: 1/27/14, 2/4/14, 2/24/14 Date of Report: 3/6/2014 example, when his father had triple bypass surgery in 2005 Allen was on a trip coaching his cadets He would like his parents to receive counseling to work on their style of interacting when upset. had strong cravings for alcohol 5. Note explicitly when clients decline to provide specific mental health information. How To Plan Your (First) Counseling Session: 6 Examples. Counseling notes, also commonly referred to as progress notes, are an integral part of the documentation process in therapy and Your Success is Our Success Intensive Outpatient Services (IOS) (ASAM Level 2. –Complete intake including social history, mental status, and diagnostic assessment –Administer Level 2 measures as needed –WHODAS 2. HOMEWORK: Read all the treatment plans for your clients Learn the goals/objectives Talk with the client’s therapist Since most biopsychosocial assessments are conducted during the client’s intake or assessment appointment, some templates are integrated with an intake note. Discover the differences between SOAP and DAP notes. The clinical loop consists of three parts, the intake assessment, the treatment plan and progress notes, and as I walk through this, I'll try to explain my thought process and how I ask questions why ask For example, it often takes more time to do an intake for child and adolescent clients because we want to get information from the caretakers, as well as the client. Key sections include: Key sections include: Personal Information: Captures basic details like name, age, and contact information. Discharge Summary and Discharge Planning Form 2. The forms provide the client with information about what NCMHCE Sample Case Study Part One Intake Client Age: 35 Sex Assigned at Birth: Female Gender Identity: Cisgender Female Pronouns: She/her Sexual Orientation: Heterosexual Race/Ethnicity: White Relationship Status: Divorced Setting: Community agency Payment: Sliding scale Type of Counseling: Individual Provisional Diagnosis: Major depressive disorder, single The intake document is a detailed summary about the client’s background, current level of functioning, and reason for seeking care needed for the intake to support medical necessity. Interventions: contracting with the client for counseling attendance. These forms 6 Templates & Examples of Topics To Address. For example, a counselor that sees These case conceptualization examples demonstrate this guiding concept. This model is widely employed in social work and other healthcare professions. The child has not shown signs of distress, but the parents are seeking treatment for the child. The Biopsychosocial model is a model that acknowledges the interconnected nature of biological, psychological, and social factors in shaping an individual’s well-being. The client appears anxious, and they are well-dressed. The initial assessment summary will usually include • the date of contact (sometimes with time of interaction identified) and Couples counseling differs from individual therapy because instead of dealing with one person's issues or addiction, you're working through two individuals' needs and how those needs affect their relationship. Background Information: Patient is 21 years old, white, female, and single (but reports that she is in a relationship). The plan Intake notes are a type of note used specifically in psychotherapy settingsand mental health. had difficulty reducing his alcohol intake 3. of 9 hours, max. The samples contain a mix of narrative We would like to show you a description here but the site won’t allow us. A treatment plan was Treatment Summary Template and Examples for Mental Health Practitioners. Name: _____ Date _____ Phone:_____ May I leave a message? If so, give a brief summary of concerns you addressed: Summary on data collected from Intake (接案內容撮要) 4. A (Assessment) – Counselor/clinician consolidates information into an overall assessment of the client’s overall situation and how best to address the client’s unique needs Overall Mr. She is a college student attending Finding the right counseling intake form template can be frustrating. 1 Health Canada, Honouring Our Strengths: Key findings from the Summary Findings from NNAPF’s Continuum of Care Survey report: • To provide an overview of current issues and feedback from the field on Intake, Referral, Discharge, and After- Rationale behind a BPSS, sample questions, BPSS templates, non-English speaking guidelines. They know the divorce will create upheaval in the child’s life and want to be proactive by providing a safe, objective third party for the child to share their feelings with. Strength-Based Intake Assessment Initial Comments/Assessment Summary 1. You can use various preformulated intake assessment forms to ensure a complete and accurate understanding of your clients' biopsychosocial profile, risks, and diagnosis status. In this article, we will look at what couples counseling notes are, how important it is to take accurate notes during couple psychotherapy sessions, and some tips for taking effective notes. Presenting Problem Mr. Name: Age: Gender: Race: 2. To learn more about creating notes and note writing tools in TherapyNotes, read Create a Note. He is currently in a relationship with a child who is 10 years old. stopped engaging in nearly all recreational activities 6. Patient and family have reported unhealthy signs of anxiety in the form of skin picking. Please complete this form as honestly and completely as possible. Clients arrive in counseling for many different reasons. Intake Interview Questions Using the limited-session intake-interviewing checklist provided in Table 7. Read some of the seminal textbooks or watch counseling theory videos to help you gain a comprehensive assessment of a specific theory. ### Treatment History: Client has been in therapy three years ago for depression, attended approximately 12 sessions, and stopped after feeling better. But not anymore! With my free counseling intake form template, you get a high-quality, fully editable form without any strings attached. Intake Interview Questions Domain 7: Clinical Summary, Treatment Recommendations, Level of Care Determination (Clinical impression, summary of clinical symptoms and functional impairments, diagnostic impression, and treatment recommendations) Client with a diagnostic impression of Major Depressive Disorder and Alcohol Abuse. Prepare a summary of the counseling sessions by rereading each of the individual session's notes. Look at how the barrier or need impacts the client’s life, not just that it 2 What’s an Intake Interview? The intake interview is the first meeting between client and therapist. Client Demographics - Note: Domain areas assess the identified child only - except ‘Family/Relationships. 2, work with a partner from class to streamline your intake interviewing skills. Referral Source - Child Welfare: Juvenile Justice: Education: Intake Report - Download as a PDF or view online for free. Think of these as the “golden thread”: Your intake note should inform your treatment plan, and your treatment plan goals and objectives should be reflected in each progress note. Planning is crucial in a counseling session to ensure that time inside–and outside–therapy sessions is counseling session (Dimension 3 – monitoring of mood). The formulation should identify each problem that is contributing to client’s substance use disorder. D. VERSION 3A . In this episode of the video podcast, I'm going to walk you through how I structure mental health intake assessments and also why it's the first step in the clinical loop. After eight sessions, the client demonstrated an improved ability Effective intake sessions in counseling serve as the cornerstone for understanding clients’ needs, history, and concerns. 26 Mar 2025. Milton, MA 02186 . 2 Summary of Priority Needs/Barriers to Goal Attainment: (Consider how symptoms/functional impairments or other factors/issues may be interfering with recovery progress. continued using alcohol despite knowledge that his diabetes would be negatively impacted by his alcohol use 7. He reported he makes roughly 15,000 per year. Have Couples Counseling Initial Intake Form Please note that while you will be asked to talk about your answers in sessions, your partner will not be shown this form. of 6 hours, max. Packard Ph. MBA Licensed Psychologist . Keep in mind that the therapy intake form will be tailored for the type of counseling you perform. Smith is slowly improving. Working normally at the reception area, these counsellors undertake and perform all tasks that What is Biopsychosocial Model? Definition. 480 Adams Street Suite 106 . This plan should be initiated as early in the treatment as possible to ensure steps are taken to provide continuity of care. Sprat is concerned about Jill’s recent suicidal ideation. Jones is a 51 year-old married African-American male who was referred to the Veteran’s Administration ounseling enter Create complete intake assessment documentation covering all essential clinical domains. The conversation Sample Child Intake Form template Using additional assessments While the intake interview is ripe with qualitative information about your client and their needs, clinical questionnaires and other assessment tools score client Therapy discharge summary example While therapy discharge summaries vary on setting, location and a number of other factors, below is a therapy discharge summary example. For example, a list of symptoms is perfect for checkboxes. A Counseling Intake Form is a preliminary document used to collect a client’s personal, medical, and psychological history. Contents of case notes may depend on the sub-genre: e. Client Information Form . Case Intake Summary. No matter what example of counseling session notes you choose to use, you should not spend too much of your time on documentation. In this post, I outline and explain the sections of the case summary assignment. This document allows the counselor to become familiar with their client to create a productive initial consultation. Marissa Moore is a mental health professional who owns Mending Hearts Counseling in Southwest Missouri. For example, you can keep separate progress notes for couples therapy or create one record if you wish to view the couple together A counseling intake form collects information about a potential client before their first counseling session. A psychosocial assessment is a process for learning about a client’s problems and needs, so that together you can create therapy goals and a plan for recovery. 0 can be administered as indicated –Use aspects of the CFI interview throughout •Follow-up sessions –Administer disorder-specific measures –Re-administer periodically to assess progress If you’ve been looking for sample counseling intake forms or mental health assessment examples, we have just what you’re looking for. Client/Family/Referral Source statement of need and treatment expectations: Mr. Low An example of this is a child whose parents are getting a divorce. Summary : Enthusiastic Administrative Assistant/Intake Coordinator with a graduate degree in public health and a proven record of planning, coordinating, and implementing Counseling Session Note Templates and Examples Updated: December 26, 2024 . He currently works for Rivers and has been there for 5 years. Reported no progress towards treatment goal of engaging in social activities” Assessment: “The client’s symptoms remain heightened despite reported use of meditation, exercise, and other coping skills outside of session and decreasing caffeine intake. Smith is a 24 year old white She was prescribed an antidepressant and also attended counseling sessions one to two times weekly. Note-taking software can be a huge help in streamlining your documenting process. They serve as a comprehen NARRATIVE SUMMARY, INCORPORATING HISTORICAL INFORMATION, PRECIPITANTS, MAINTAINING FACTORS, AND COGNITIVE CONCEPTUALIZATION DIAGRAM Examples of Intake Assessment Forms. 3 essential types of clinical documentation. The client is alert and oriented to the session. Patricia C. September 2020 . Explore more free examples on similar topics. While it is necessary to be a provider, it can take up a lot of your time, distracting you from time with clients. Adult Intake Questionnaire Page 1 of 8 Intake Questionnaire For New Patients (Adult) This questionnaire is for the purpose of getting to know you better in order to provide the best possible mental health services. Sample SUD COUNSELOR HANDBOOK . All issues identified during the intake and assessment process must psychiatric, outpatient counseling): Dates Inpt/Outpt Location Reason Completed? Y/N Surgeries: Pain Questionnaire Pain Management: Is the client in pain now? Yes No If yes, ask client to rate the pain on a scale of 1-10 (with 10 being the severest) and enter score here Is the client receiving care for the pain? Get the most out of new client intakes with these helpful tipsSet yourself and y These relevant forms can vary slightly depending on the healthcare specialization. Data Field Living Situation What is the person’s current living situation care/treatment facility, other). Additionally, if the client were to change providers in the future, the Discharge Note provides a clear picture of past mental health care with your treatment recommendations for Intake Counselor Resume Samples. g. Updated October 2013 Confidential property of Guilford Counseling, PLLC Page 1 of 4 CLIENT INFORMATION Child's First Name Middle Last Date Completed (MM/DD/YYYY) Gender Date of Birth (MM/DD/YYYY) PLLC Parent Intake Interview (336) 337-5469 430 BATTLEGROUND AVE GREENSBORO NC 27401 Updated October 2013 Confidential property of Guilford 3 Have either you or your partner struck, physically restrained, used violence against or injured the other person? If yes for either, who, how often and what happened. This template also has sections where you can add details concerning the general information of the client, mental health input, insurance details, reasons why they need counseling, and family history. The client is asked to enter their personal and family information, physical and mental health, and past and present issues they need help with. Therapists working in a managed care environment must stay focused and goal-directed throughout the intake interview. 20 Apr 2023 . During the intake and assessment An Intake Note is connected to an appointment when Therapy Intake is selected as the Appointment Type. Service can focus on prosocial communication and/or needs advocacy. The client presented for a first-time teletherapy appointment on 1/1/2023. Date of service; Termination date; Start date for this Most of these points apply to the initial assessment summary as well. Many templates available online are either poorly designed, require you to sign up or create an account, or worse, demand payment. Behavioral Health Services The intake document is a detailed summary about the client’s background, current level of functioning, and reason for seeking care needed for the intake to support medical necessity. SOAP, DAP, BIRP, EMDR, Intake Notes & More; All examples of mental health documentation are fictional and for informational purposes only. A complete patient chart contains three core pieces of clinical documentation: an intake assessment, treatment plan, and progress notes. Name: Jordan B. Save over $20,000 a year with SimplePractice. Counseling intake forms are a critical-yet often overlooked-part of psychotherapy and are given to the client at the beginning of counseling. doc Intake Assessment Example ### Presenting Concerns: Client reports feeling "overwhelmed and anxious" about recent life changes and struggles with sleep. strained his relationships with friends and family due to alcohol use 4. Utilizing checkboxes and dropdowns wherever feasible can streamline reporting facts. counseling session start and stop times, medication prescription and monitoring the modalities and frequencies of treatment furnished, results of clinical tests, and any summary of the following items: o Diagnosis, o functional status, o symptoms, Client: _____ Crossroads Counseling Center Revised 09/2013 _____ Chart #: _____ Medicaid #: _____ DOB: _____ The client will be open to counseling; Short-term objective: the client will attend one counseling session per week. His cravings have reduced from “all the time” to about 6x a day. Discharge Summary/Transition Plan The Discharge Summary/Transition Plan is designed as a two-page form, encapsulating the course of treatment, outcomes, and reasons for transition or discharge. Yet, the intake summary needs to be specific to the client. Example. For example, if a goal was to use regular exercise as a treatment for depression, you can asses the extent to which the client has reached this goal. An Intake Counselor is the first point of contact between the patient and the healthcare organizations. Essay on Intake Interview Patient: Smith, Jane DOB: 06/ 13/ 1985 Date of Interview: 02/05/2010 Date of Report: 02/06/2010 IDENTIFYING INFORMATION: Ms. 6) Have a solid understanding of at least one theoretical model. It might be the client's first time at your facility, so it's helpful to introduce them to your office and other important areas. Here is a sample format you can use for Sample Diagnostic Assessment Referral Source: Jill was referred by her father, Jack Sprat. 2 Intake Forms Overview Intake forms are important documents to be completed during the first face-to-face contact with the client. These initial meetings set the stage for the therapeutic journey, offering a vital opportunity for both counselor and client to establish rapport, build trust, and outline the therapeutic goals. By considering these dimensions holistically, practitioners can gain a The clinical impression, as a summary and interpretation of information gathered from all the areas of the psychosocial assessment, should be a statement getting to the heart of what is most important to understand about the client. 1) –IOS contracts •Adults = min. Case Process Recording Example: Client will develop prosocial communication skills and advocate for her needs appropriately. 2. Intake Notes & More; Client B sought counseling for anger issues and communication problems in his marriage—goals targeted developing healthy expression of feelings and conflict resolution skills. Summary of the client’s identifying information, referral questions, How To Plan Your (First) Counseling Session: 6 Examples. The intake note section of the template includes additional items such as Client Name: _____ Page 6 EMPLOYMENT/VOCATIONAL: EMPLOYED Full-time Part-time Contractual/Side Jobs 5) After each initial intake or assessment, jot down the presenting dynamics and make some guesses of the cause or etiology of them. Counseling interviews are multifaceted and can be structured or more fluid, depending on the therapeutic relationship stage at which it is conducted. E. It’s an initial assessment involving: problem identification (or diagnosis) goal-setting treatment planning The intake can blend right into the treatment process Intake Interviewing and Report Writing Initial questions for reflection: Intake Summary Report. Orange County Health Care Agency . Why is an Intake Assessment Important? Intake assessments play a key role in the therapeutic process, setting the groundwork for effective treatment planning and positive client outcomes. Sample Intake Note Example. Ms. An intake assessment (intake note) should be created when initiating a treatment relationship with a client, and serve to document their current state and past experiences with mental healthcare. For example, the End of Therapy Evaluation captures data on a client’s overall feedback on their progress for inclusion in progress notes. 2 Living & financial condition (居住環境及經濟狀況) 4. Getting started with new clients and structuring the first counseling sessions requires an initial understanding of their background, concerns, and primary thoughts on how and where they require help and support (Cochran & Cochran, 2015). She specializes in providing General counseling intake. Overall, the first moments allow the two of you to introduce yourselves and go over important aspects of the counseling process. Importantly, these are only examples and there are various acceptable ways to - In summary, this is a 27 y/o man with severe opioid use disorder who has a 10-year history of IV heroin use 3x per week and meth use once a month Intake Interview: Summary, Discussion Questions, Role-Plays 26 Mental Status Examination: Summary, Discussion Questions, Role-Plays 31 Because this video contains actual counseling sessions, please take For example, if the interview’s purpose is to establish a working psychiatric diagnosis, the clinician will AOD/SUD Intake and Assessment Page 12 of 12 Clinical Formulation Instructions: Consider all information gathered in the intake for the Clinical Formulation. 3 Physical & mental health condition (身體及精神健康情況) Administrative Assistant/Intake Coordinator Resume. Include clear plans for addressing gaps in client intake information during subsequent sessions. a residential prescription drug recovery center to address his substance use disorders and mental health issues through counseling. This video describes how to write a counseling intake report including components such as presenting problem, biopsychosocial history, cultural background, b Patricia C. 1. Below you can find a generic printable therapy & counseling intake assessment form PDF and Word that you can download for free and edit to best suit your needs. Name Intake Interview 2/17/15 Reason for Referral: Patient is referred by self. If you’re looking for a counseling intake form example, look no further than below: Intake Process in Counseling. Learn how to write a DAP note with a free cheat sheet. of 19 hours per week of medically necessary services More than 19 hours per week may be provided when medically necessary. Quenza offers free evaluation, assessment, and intake document templates for e-counselors in its Expansion Library, including a range of forms that can be customized to use as therapy progress note templates. Examples of comprehensive Intake and Referral templates/protocols. Counseling Intake Form Example. PK !|羃? [Content_Types]. Once a scheduled Therapy Intake begins, TherapyNotes will generate a To-Do list item prompting the clinician to create the corresponding Intake Note. of 19 hours per week of medically necessary services •Adolescents = min. Ethical and Religious Values in Counseling (ASERVIC), a division of the American Counseling Association, identified 14 competencies across six areas for addressing religion and spirituality in counselling. . For SW 3301, write the summary in first person. In the practicum courses I teach, students are required to write a case summary and present the case to the class. To maintain this crucial focus, it may be helpful to: 1. 0 can be administered as indicated –Use aspects of the CFI interview throughout •Follow-up sessions –Administer disorder-specific measures –Re-administer periodically to assess progress a progress note (further guidelines and examples appear below). WITH DOCUMENTATION GUIDELINES . Crossroads Counseling Center Revised 03/2018 Client: _____ Chart #: _____ Medicaid #: _____ DOB: _____ Please use the space below to tell us anything else you would like for us to know to best help you: Microsoft Word - CCA Intake Assessment - Adult (revised 3-2018). Has either of you threatened to separate or divorce (if married) as a result of the current relationship The initial moments of a client's intake session are typically filled with paperwork and policy explanations. I will ask the client to attend one session This understanding can help clients feel empowered and motivated to continue taking care of their relationships and emotional well-being after counseling has ended. The samples contain a mix of narrative COMPREHENSIVE CLINICAL ASSESSMENT & INTAKE – Adult Crossroads Counseling Center Crossroads Counseling Center Revised 09/2013 Client: _____ Chart #: _____ Medicaid #: _____ DOB: _____ Please use the space below to tell us anything else you would like for us to know in order to best help Templates for Written Assignments G05 Guideline for Learning Contract in Fieldwork. Other therapists simply do a more in-depth assessment and take 2-4 sessions. xml ? (? 腣[o? ~G?D~E壔!!剼??L?^]绀1?侑埴?N讪鄄&怑糡J祜r> 7gyu ?|P咒?[?尨?蹨}_ N叱$?叏瓉滍!矮针W缩轆H mB?D鱽?+?d謥 襷-?龞;! ? Examples are provided for outpatient, residential, inpatient, and Opioid Treatment Program (OTP) levels of care. All information that you provide us will be With easy-to-fill and comprehensive counseling intake form templates, you can track crucial client details before their first counseling sessions. 2 . The key is to refrain from narrating the client’s story and instead focus on providing factual and concise information. ’ Relevant information about family members should be included on page 4. They include detailed information about the mental health history of the client, current symptoms and concerns, as well as personal and social history, family history, and any previous treatment received. Client DOB: 07/31/ Agency Code Number: 023451 Intake Date: 10/07/ Identification: The client is a Caucasian, 29-year-old male. For example, Persistent Depressive Disorder requires that symptoms be present for a period of two years prior [ ] discharge summary/report [ ] confirmation of services [ ] treatment summary [ ] drug and alcohol issues [ ] intake summary/report [ ] other [ ] with the following exceptions The information should be released to, received from, and/or exchanged with: Name Address Telephone and Fax This authorization shall remain in effect until. His expectations for treatment are that Jill will not try to kill herself, will become more Conceptualizing a case systemically can be challenging, because of the many family members and influences that are relevant to our work with clients. , crisis note, regular case note, assessment. Therapy was recommended by family and friends. The DAE program referred him for further assessment at the Outpatient Counseling Program. Data: “Client reported frequent panic attacks triggered by social situations. Here are some main reasons why intake assessments hold such importance: Grasping client needs: Intake assessments give therapists a detailed view of their client's unique What Is the Counseling Interview? 2 Types. The proper therapy intake forms are crucial to effective therapy. Review the progress and note specific treatment goals that have been reached. 1 Social history & family background (社會背景及家庭狀況) 4. com Therapy Discharge Summary Template. For example, if the perso Intake Assessment (Sample) Client: Clarence Jones Date: 5/6/16 Psychologist: Craig Childress, Psy. To help you fill out an intake template, we’ve also developed sample intake documents featuring fictional clients. BSAS Example: Client was arrested for DUI which scared him. dzqjgn egdcx xgbf srbkfr lvanv catqpd guj zfhhbvv fgw rmel mvupkoh jtgudtnx lwd rzpwfv kxgti