Complete therapy intake and mental health assessment template with all required sections. Use this free template as a reference or let SOAP Note Buddy auto-fill your evaluations.
What is a Mental Health Evaluation?
A mental health evaluation (also called a psychiatric intake, psychotherapy intake, initial assessment, or biopsychosocial assessment) is a comprehensive assessment performed by a mental health professional at the start of treatment. It establishes the clinical picture, formulates a diagnosis, identifies risk factors, and creates the treatment plan.
The mental health evaluation is the foundation of effective psychotherapy. It serves multiple critical purposes:
Clinical Conceptualization: Develops a comprehensive understanding of the client's presenting problems, history, and functioning
Diagnosis: Applies DSM-5-TR criteria to establish primary and differential diagnoses
Risk Assessment: Identifies safety concerns including suicidal ideation, homicidal ideation, and self-harm
Treatment Planning: Guides selection of therapeutic modalities and establishes measurable goals
Medical Necessity: Documents why mental health treatment is clinically indicated
Legal Record: Creates a baseline record of the client's condition at start of care
Intake vs. Ongoing Sessions
The intake evaluation is distinctly different from ongoing therapy sessions. Intakes are typically longer (60-90 minutes), more structured, and focused on information gathering. Subsequent sessions focus on therapeutic intervention based on the treatment plan established in the intake.
What Does a Mental Health Evaluation Include?
A comprehensive mental health evaluation follows a structured format that gathers both subjective history and objective clinical observations. Each component contributes to a complete clinical picture.
1. Presenting Problem
The client's chief complaint in their own words, including current symptoms, onset, duration, severity, and impact on functioning. This is the reason the client is seeking treatment now.
2. History of Present Illness
A detailed narrative of the current episode, including precipitating factors, symptom progression, previous treatment for this issue, and what has helped or not helped. This provides context for the presenting problem.
3. Psychiatric History
Past mental health diagnoses, hospitalizations, medication trials, previous therapy experiences, and treatment outcomes. This history informs current treatment planning and helps avoid repeating unsuccessful interventions.
4. Medical History and Substance Use
Current medical conditions, medications, and substance use patterns. Many medical conditions and substances can cause or exacerbate psychiatric symptoms, making this history essential for differential diagnosis.
5. Family and Social History
Family psychiatric history, developmental history, educational and occupational background, relationships, living situation, and support systems. This biopsychosocial context shapes treatment approach.
6. Mental Status Examination (MSE)
A systematic assessment of the client's current mental state including appearance, behavior, speech, mood, affect, thought process, thought content, perception, cognition, insight, and judgment. This provides objective clinical data.
7. Risk Assessment
Evaluation of suicidal ideation, homicidal ideation, self-harm, and other safety concerns. Includes assessment of risk and protective factors, with documentation of safety planning when indicated.
8. Diagnosis and Treatment Plan
DSM-5-TR diagnosis with clinical justification, treatment goals, recommended interventions, session frequency, and coordination of care. This roadmap guides the therapeutic work ahead.
Complete Mental Health Evaluation Template
Below is a comprehensive mental health evaluation/intake template. You can use this as a reference for manual documentation or let SOAP Note Buddy auto-generate evaluations in your EHR.
Client Information
Client Name
[Client Name]
Date of Birth
[DOB]
Date of Evaluation
[Date]
Referral Source
[Self, PCP, Other Provider, etc.]
Insurance/Payment
[Insurance or Self-Pay]
Emergency Contact
[Name, Relationship, Phone]
Presenting Problem
Chief Complaint
[Client's primary reason for seeking treatment, in their own words. What brings them to therapy now? Include the specific symptoms or concerns that prompted the referral.]
History of Present Illness
[Detailed narrative of current symptoms including onset, duration, frequency, intensity, precipitating factors, course (improving/worsening/stable), and impact on daily functioning. What was happening when symptoms began? How have they changed over time?]
[How symptoms affect work/school, relationships, self-care, and daily activities. Include specific examples of impairment.]
Psychiatric History
Previous Diagnoses
[Prior mental health diagnoses, when diagnosed, by whom. Include any diagnoses the client disagrees with or questions.]
Previous Psychiatric Hospitalizations
[Dates, facilities, reasons for admission, length of stay. Include voluntary vs. involuntary status if known. "None" if no history.]
Previous Outpatient Treatment
[Prior therapy experiences including approximate dates, type of therapy, duration, and outcome. What was helpful? What was not helpful? Reason for termination.]
Psychiatric Medications (Current and Past)
[Current: Medication name, dose, prescriber, duration, response.
Past: Previous psychiatric medications tried, doses, response, reason discontinued. Include any adverse reactions.]
Medical History and Substance Use
Medical Conditions
[Current medical diagnoses, particularly those that may affect mental health (thyroid, chronic pain, neurological conditions, etc.). Include date of last physical exam.]
Current Medications (Non-Psychiatric)
[All current medications, supplements, and OTC drugs with dosages.]
Allergies
[Medication allergies and reactions. "NKDA" if none.]
Substance Use History
Alcohol Use
[Current use: frequency, quantity, last use. History of problematic use. Prior treatment for alcohol use disorder. "Denies" if none.]
Cannabis Use
[Current use: frequency, method, last use. "Denies" if none.]
Other Substance Use
[Other substances (prescription misuse, stimulants, opioids, etc.). Current and past use. Treatment history. "Denies" if none.]
Tobacco/Nicotine Use
[Current use, type, frequency. "Denies" if none.]
Family and Social History
Family Psychiatric History
[Mental health conditions in family members (parents, siblings, children, grandparents). Include substance use disorders, suicide attempts/completions. "Unknown" or "Denies" if no known history.]
Developmental History
[Birthplace, developmental milestones, childhood environment, significant childhood experiences, trauma history. Early attachment relationships.]
[Understanding of illness and need for treatment. Examples: "Good - recognizes connection between symptoms and stress"]
Judgment
[Decision-making capacity. Examples: "Fair - some impulsivity with financial decisions"]
Impulse Control
[Ability to regulate impulses. Examples: "Intact," "Poor - history of impulsive anger outbursts"]
Risk Assessment
Safety Assessment Required
All mental health evaluations must include thorough risk assessment. Document carefully and implement safety planning when indicated.
Suicidal Ideation
Current Suicidal Ideation
[Present/Absent. If present: passive vs. active, frequency, intensity, duration. "Denies current suicidal ideation" if absent.]
Suicidal Plan
[If ideation present: Does client have a plan? Method? Means? Timeline? "Denies plan, intent, or means" if no plan.]
Suicidal Intent
[Level of intent to act on thoughts. "Denies intent" if no intent.]
History of Suicide Attempts
[Previous attempts: number, methods, lethality, circumstances, medical intervention required. "Denies history of suicide attempts" if none.]
Homicidal Ideation
Homicidal Ideation
[Present/Absent. If present: target, plan, intent, access to means. "Denies homicidal ideation" if absent.]
Self-Harm
Non-Suicidal Self-Injury
[Current and historical self-harm behaviors (cutting, burning, etc.). Frequency, recency, function. "Denies self-harm" if none.]
Risk and Protective Factors
Risk Factors
[Identified risk factors: previous attempts, hopelessness, impulsivity, substance use, access to means, recent losses, social isolation, chronic pain, etc.]
Protective Factors
[Identified protective factors: reasons for living, social support, religious/spiritual beliefs, children, fear of death, future orientation, engaged in treatment, etc.]
Risk Level Determination
[Low / Moderate / High / Imminent. Clinical reasoning for determination.]
Safety Plan (if indicated)
[If elevated risk: Safety plan completed? Key elements? Lethal means counseling? Crisis resources provided? Document or attach safety plan.]
Clinical Formulation and Diagnosis
Clinical Formulation
[Synthesis of presenting problem, history, MSE, and assessment. How do the biological, psychological, and social factors interact to create the current presentation? What is your clinical conceptualization?]
DSM-5-TR Diagnosis
[Primary Diagnosis: (Disorder name, ICD-10 code)
Example: Major Depressive Disorder, Single Episode, Moderate (F32.1)
Secondary Diagnosis (if applicable): (Disorder name, ICD-10 code)
Example: Generalized Anxiety Disorder (F41.1)
Include specifiers when applicable. Note "rule out" diagnoses if further assessment needed.]
Differential Diagnosis
[Other diagnoses considered and ruled out, with reasoning. Diagnoses that require additional assessment to confirm or rule out.]
Prognosis
[Expected outcome with treatment - Good, Fair, Guarded, Poor. Factors supporting prognosis (motivation, insight, support system, chronicity, complexity).]
Treatment Plan
Treatment Goals
[Measurable, specific goals developed collaboratively with client:
1. [Goal 1 - e.g., "Reduce depressive symptoms as measured by PHQ-9 from 18 to <10 within 12 weeks"]
2. [Goal 2 - e.g., "Develop and consistently use 3 coping strategies for anxiety management within 8 weeks"]
3. [Goal 3 - e.g., "Improve sleep hygiene to achieve 6+ hours of quality sleep per night within 6 weeks"]]
Treatment Modality
[Recommended therapeutic approach(es): CBT, DBT, psychodynamic, EMDR, ACT, motivational interviewing, supportive therapy, etc. Rationale for selection.]
Session Frequency and Duration
[Recommended frequency (weekly, biweekly, etc.), session length (45-60 min), and estimated treatment duration. Example: "Individual therapy, 50-minute sessions, weekly x 12 weeks, then reassess."]
Medication Recommendations
[Referral for medication evaluation? Current prescriber coordination? "Not indicated at this time" or "Will coordinate with prescriber [name]" or "Refer to psychiatry for evaluation."]
Additional Recommendations
[Other recommendations: psychological testing, group therapy, support groups, case management, higher level of care, lifestyle modifications, etc.]
Coordination of Care
[Other providers involved in care, releases obtained, planned communication. Primary care, psychiatrist, other specialists, school, etc.]
Barriers to Treatment
[Identified barriers: transportation, finances, childcare, work schedule, ambivalence, etc. Plan to address barriers.]
Informed Consent and Signatures
Informed Consent Documentation
[Informed consent reviewed and signed: Yes/No. Topics discussed: confidentiality and limits, risks/benefits of treatment, emergency procedures, fees/billing, cancellation policy, telehealth consent if applicable.]
Client Agreement to Treatment Plan
[Client verbalized understanding and agreement with diagnosis and treatment plan: Yes/No. Any concerns or modifications discussed.]
Clinician Signature
[Signature]
Credentials
[LCSW, LPC, LMFT, PhD, PsyD, etc.]
License Number
[License #]
Date
[Date]
Tips for Thorough Mental Health Assessments
Conducting comprehensive mental health evaluations is both an art and a science. Here are tips to help you gather complete information while building therapeutic rapport.
Build Rapport First
The intake is often the client's first impression of therapy. While you need to gather extensive information, prioritize connection over completion. A client who feels heard and understood will provide more accurate and complete information. Start with open-ended questions before moving to structured assessment.
Be Thorough with Risk Assessment
Never skip or rush through safety questions. Ask directly about suicidal and homicidal ideation - research shows that asking about suicide does not increase risk. Document your assessment thoroughly, including both positive and negative findings. "Denies SI/HI" is insufficient - document the specifics of what was asked and answered.
Use Standardized Measures
Incorporate validated screening tools (PHQ-9, GAD-7, PCL-5, etc.) to quantify symptom severity and track progress. These provide objective data points and support medical necessity. Include baseline scores in your evaluation and plan for readministration.
Document Medical Necessity
Your evaluation should clearly establish why mental health treatment is clinically indicated. Connect symptoms to functional impairment. Insurance reviewers look for: specific symptoms, measurable impairment, and treatment that only a licensed clinician can provide.
Consider Cultural Context
Cultural background affects symptom presentation, help-seeking behavior, and treatment expectations. Document cultural factors that may influence diagnosis and treatment. Use the DSM-5-TR Cultural Formulation Interview when appropriate.
Collaborate on Treatment Planning
Treatment plans developed with client input have better outcomes. Discuss diagnosis, explain your clinical reasoning, and develop goals together. Document that the client agreed to the treatment plan.
Quality Over Speed
A thorough intake prevents problems down the road - missed diagnoses, inappropriate treatment, or safety concerns. If you cannot complete the evaluation in one session, schedule a second intake session rather than rushing through critical sections.
How SOAP Note Buddy Helps with Mental Health Evaluations
Mental health intake evaluations are the most documentation-intensive part of therapy practice. A comprehensive biopsychosocial assessment can take 45-90 minutes to document manually - time that cuts into patient care or your personal life.
Generate Complete Evaluations in Minutes
SOAP Note Buddy uses AI to dramatically speed up your evaluation documentation. Enter your client's key information and the AI generates a complete evaluation draft in your EHR.
What SOAP Note Buddy Does:
Auto-Detects Your EHR Fields: Works with SimplePractice, TherapyNotes, Jane App, and any web-based system
Generates All Sections: History, MSE, risk assessment, diagnosis, and treatment plan
Understands Mental Health Terminology: Uses correct clinical language for DSM diagnoses, therapeutic modalities, and assessment findings
Supports Multiple Formats: Works with SOAP, DAP, BIRP, and biopsychosocial formats
HIPAA Compliant: Client information is protected with automatic PHI removal before AI processing
No Recording Required: Unlike other AI scribes, we don't require session recordings
What used to take 45-90 minutes now takes 5-10 minutes of review and customization. That's your evenings and weekends back.
AI Documentation Best Practices for Mental Health Evaluations
Always Review Risk Assessment: AI can help structure your documentation, but clinical judgment about safety is always your responsibility.
Verify Diagnostic Accuracy: Ensure AI-generated diagnoses match your clinical assessment and DSM-5-TR criteria.
Customize Treatment Plans: Adjust AI-generated goals to reflect your specific therapeutic approach and the client's needs.
Add Your Clinical Reasoning: Supplement AI drafts with your unique clinical insights and case conceptualization.
Review Before Signing: AI is a draft generator, not a replacement for clinical judgment. Always review the complete document.
Frequently Asked Questions
What should be included in a mental health evaluation?
A comprehensive mental health evaluation includes: presenting problem and chief complaint, history of present illness, psychiatric history (diagnoses, hospitalizations, medications), medical and substance use history, family and social history (including developmental and trauma history), mental status examination, risk assessment (SI, HI, self-harm), DSM-5-TR diagnosis with clinical formulation, and treatment plan with measurable goals.
How long should a mental health intake evaluation take?
A comprehensive mental health intake typically takes 60-90 minutes for the clinical interview, depending on complexity. Documentation can take an additional 30-60 minutes if done manually. AI documentation tools like SOAP Note Buddy can reduce documentation time to 5-10 minutes, allowing you to complete notes between sessions.
What is the difference between a mental health evaluation and a psychiatric evaluation?
A psychiatric evaluation is typically conducted by a psychiatrist or psychiatric nurse practitioner and focuses more heavily on medication management, medical differential diagnosis, and biological aspects of mental illness. A psychotherapy intake conducted by therapists (LCSWs, LPCs, psychologists) focuses more on psychosocial factors, therapy treatment planning, and therapeutic intervention. Both include similar core components like MSE and diagnosis.
What is included in a mental status exam?
A mental status examination (MSE) is a systematic assessment of the client's current mental functioning. It includes: appearance (grooming, hygiene, attire), behavior (eye contact, psychomotor activity), speech (rate, rhythm, volume), mood (subjective emotional state), affect (observed emotional expression), thought process (organization of thinking), thought content (themes, delusions, obsessions), perceptions (hallucinations), cognition (orientation, attention, memory), insight, and judgment.
How do you document risk assessment in a mental health evaluation?
Document risk assessment by explicitly asking about and recording: suicidal ideation (presence, passive vs. active, frequency), suicidal plan (method, means, timeline), suicidal intent, history of attempts, homicidal ideation (target, plan, intent), and self-harm behaviors. Then document identified risk factors, protective factors, overall risk level determination (low/moderate/high), and any safety planning conducted.
What CPT codes are used for mental health evaluations?
Mental health evaluations typically use CPT code 90791 (psychiatric diagnostic evaluation without medical services) for therapists, or 90792 (with medical services) for prescribers. Some practices also use 90837 (60-minute psychotherapy) for extended intake sessions. Insurance requirements vary - check with specific payers for their intake documentation requirements.
How often should mental health evaluations be updated?
Treatment plans should be reviewed and updated regularly - typically every 90 days or as clinically indicated. A full re-evaluation may be needed when there's a significant change in symptoms, new diagnoses emerge, treatment approach needs major modification, or the client returns after a gap in treatment. Many insurers require updated treatment plans for continued authorization.
Can AI help with mental health evaluations?
Yes. AI documentation tools like SOAP Note Buddy can significantly reduce evaluation documentation time. You provide the clinical findings, and the AI generates a complete evaluation draft including all standard sections. You review and customize the output, saving 30-60 minutes per intake. The AI understands mental health terminology including DSM diagnoses, therapeutic modalities, and MSE components.