A psychiatric intake note is the foundational document that launches effective mental health treatment. This initial evaluation captures a client's presenting concerns, clinical history, and mental status in a structured format that guides diagnosis and treatment planning.

For psychiatrists, psychiatric nurse practitioners, and other prescribing mental health professionals, mastering intake documentation is essential for clinical excellence, legal protection, and reimbursement accuracy.

Key Takeaways

• Comprehensive intake notes establish the treatment foundation by documenting presenting problems, psychiatric history, and baseline mental status—creating a roadmap for ongoing care and measuring treatment progress over time.

• Standardized documentation templates ensure consistency across providers while capturing all required components including chief complaint, history of present illness, mental status examination, risk assessment, and treatment planning.

• Proper intake documentation serves multiple functions beyond clinical care, including legal protection, insurance billing accuracy, care coordination with other providers, and compliance with regulatory standards like HIPAA.

Required Components of a Psychiatric Intake

Every psychiatric intake note should follow a consistent structure that captures both clinical and administrative information. While institutional formats may vary slightly, certain core elements appear in virtually all comprehensive psychiatric evaluations.

Chief Complaint

The chief complaint represents the client's primary reason for seeking psychiatric care, ideally documented in their own words. This brief statement—typically one to two sentences—captures what brought the person to your office today.

Document this section using quotation marks when possible to preserve the client's language: "I haven't been able to sleep for three weeks and I'm falling apart at work" provides more clinical texture than a provider's interpretation like "insomnia and work stress."

History of Present Illness

The HPI section tells the story of how the current psychiatric presentation developed. This narrative should establish symptom onset, progression, severity, and context while identifying potential triggers and maintaining factors.

Include specific details about symptom frequency, duration, and intensity. Document what makes symptoms better or worse, how symptoms affect daily functioning, and what prompted the person to seek help now. A thorough HPI should answer: When did symptoms begin? How have they changed over time? What precipitating factors were present? How do symptoms impact work, relationships, and self-care?

Past Psychiatric History

This section captures the client's lifetime psychiatric treatment history, including previous diagnoses, hospitalizations, medication trials, and psychotherapy experiences. Documenting what treatments have been attempted—and their outcomes—prevents repeating ineffective interventions.

Include specific medication names, dosages, duration of trials, and reasons for discontinuation when available. Note any psychiatric hospitalizations with approximate dates and circumstances.

Medications and Allergies

Create a comprehensive list of current psychiatric and medical medications, including dosages, frequencies, and prescribing providers. This information prevents dangerous drug interactions and informs treatment planning.

Document known drug allergies with specific reactions experienced. Distinguish between true allergies (which involve immune system responses) and side effects or intolerances.

Substance Use

Substance use assessment is critical in psychiatric evaluation since substance use disorders frequently co-occur with other mental health conditions. Document current and historical use of alcohol, tobacco, cannabis, and other substances.

Use specific quantities and frequencies rather than vague terms. Include age of first use, periods of abstinence, previous treatment attempts, and any consequences of substance use.

Mental Status Exam

The mental status examination provides a structured snapshot of the client's current psychological functioning across multiple domains. This systematic observation-based assessment captures appearance, behavior, speech, mood, affect, thought process, thought content, perceptual disturbances, cognition, insight, and judgment.

Document observations objectively using descriptive language. Rather than writing "client was anxious," note specific observations: "Client fidgeted continuously, made limited eye contact, and spoke rapidly." Include both abnormal findings and pertinent normal findings.

Risk Assessment

Risk assessment evaluates potential for suicide, self-harm, violence toward others, and vulnerability to exploitation. This critical component combines historical risk factors with current thoughts, intent, and access to means.

Document suicidal ideation specifically: Are thoughts present? Are they passive ("I wish I wouldn't wake up") or active ("I have a plan")? Is there intent to act? What access exists to lethal means? What protective factors are present?

Diagnosis and Treatment Plan

Conclude the intake with diagnostic formulation using DSM-5-TR criteria and a comprehensive treatment plan. List diagnoses using proper coding and specify whether they are provisional or established.

The treatment plan should address biological, psychological, and social dimensions of care. Include specific interventions, target symptoms, and follow-up timeline. Document measurable treatment goals and how progress will be monitored.

Full De-Identified Psychiatric Intake Note Example

Client Initials: J.M.
Date of Service: January 27, 2026
Provider: Dr. S.C., MD

Chief Complaint: "I can't stop worrying about everything and it's destroying my life."

History of Present Illness: J.M. is a 32-year-old individual presenting for initial psychiatric evaluation due to persistent, excessive worry occurring most days for approximately 18 months. Client reports worrying about work performance, finances, health, and relationships with intensity that feels out of proportion. Symptoms include difficulty concentrating, muscle tension in neck and shoulders, restlessness, irritability, and sleep disturbance with difficulty falling asleep due to racing thoughts.

Symptoms began gradually following a job transition 18 months ago but have progressively worsened. Functional impact includes declining work performance with missed deadlines, social withdrawal from friends, and tension in romantic relationship. Client tried mindfulness apps and exercise with minimal benefit before seeking professional help. No previous psychiatric treatment.

Past Psychiatric History: No previous psychiatric diagnoses, hospitalizations, or treatment. Client reports experiencing some anxiety during college but never sought treatment and symptoms resolved after graduation.

Medical History: Hypothyroidism (well-controlled on levothyroxine), no other significant medical conditions.

Current Medications:

• Levothyroxine 75 mcg daily

Allergies: Penicillin (rash)

Family Psychiatric History: Mother diagnosed with depression. Maternal grandmother had psychiatric hospitalization in her 40s, no specific diagnosis known.

Substance Use:

• Alcohol: 2-3 glasses wine on weekends, denies weekday use

• Tobacco: Never

• Cannabis: Occasional use (2-3 times monthly) for sleep

• Other substances: Denies

Mental Status Examination:

• Appearance: Casually dressed, appropriate grooming

• Behavior: Cooperative, good eye contact, intermittent hand fidgeting

• Speech: Normal rate and volume, articulate

• Mood: "Stressed and overwhelmed"

• Affect: Anxious, congruent with stated mood, full range

• Thought Process: Linear and goal-directed

• Thought Content: Excessive worry across multiple domains, no delusions

• Perceptions: No hallucinations reported or observed

• Cognition: Alert and oriented, attention mildly impaired by anxiety, memory intact

• Insight: Good - recognizes symptoms are excessive

• Judgment: Good - seeking appropriate treatment

Risk Assessment:

• Suicidal Ideation: Denies current and historical suicidal thoughts, intent, or plan

• Homicidal Ideation: Denies thoughts of harming others

• Self-Harm: No history of self-injurious behavior

• Risk Level: Low acute risk

Diagnostic Impression:

• F41.1 Generalized Anxiety Disorder

Treatment Plan:

1. Pharmacotherapy: Discussed medication options for anxiety. Client expressed preference to try therapy first before considering medication.

2. Psychotherapy: Referred to cognitive-behavioral therapy for anxiety management skills, weekly sessions recommended initially.

3. Lifestyle Interventions: Discussed sleep hygiene, limiting caffeine intake, maintaining exercise routine.

4. Follow-up: Return in 4 weeks to assess treatment response, sooner if concerning symptoms develop.

5. Safety Planning: Client verbalized understanding to contact emergency services or crisis line if safety concerns emerge.

Client Education: Provided information about generalized anxiety disorder and treatment options. Client expressed understanding and agreement with treatment plan.

Common Documentation Pitfalls

Even experienced psychiatric providers fall into documentation habits that compromise clinical utility, legal protection, or billing accuracy.

Omitting key sections represents the most frequent documentation error. Rushed intake appointments may result in incomplete risk assessments, abbreviated mental status exams, or missing substance use history. Using standardized templates with built-in prompts reduces this risk.

Using vague or subjective language without supporting observations undermines documentation credibility. Terms like "client seems depressed" lack the specificity needed for clinical decision-making. Replace subjective impressions with observable data: "Client demonstrated psychomotor retardation with slow speech and limited spontaneous movement."

Failing to document medical necessity jeopardizes reimbursement. Insurance payers require clear evidence that services provided were medically necessary. Connect assessment findings directly to treatment decisions.

Copying forward previous documentation without updating creates legal vulnerabilities and clinical errors. Each encounter note must reflect the current clinical presentation.

Legal and Billing Considerations

Psychiatric intake documentation serves functions beyond clinical care, creating legal records and supporting appropriate reimbursement for services provided.

HIPAA Compliance

The Health Insurance Portability and Accountability Act establishes requirements for protecting client health information. Psychiatric intake notes constitute protected health information subject to HIPAA privacy and security rules.

Store documentation using secure, encrypted systems with appropriate access controls. When sharing information with other providers, obtain appropriate client authorization unless exceptions apply for treatment coordination. Document all information disclosures in client records.

Insurance Billing and Coding

Accurate diagnosis coding using ICD-10 criteria and procedure coding using CPT codes ensures appropriate reimbursement for intake evaluations. Psychiatric diagnostic interviews typically use CPT code 90791 (without medical services) or 90792 (with medical services).

Documentation must support the time and complexity level billed. Initial psychiatric evaluations involving comprehensive history, mental status examination, risk assessment, and treatment planning generally qualify for evaluation and management coding. Include time spent when billing time-based codes.

Record Retention Requirements

State laws and professional regulations establish minimum retention periods for psychiatric records. Most jurisdictions require maintaining adult client records for at least seven years following the last service date, though some states mandate longer periods.

Records for clients who were minors when treated typically must be retained longer—often until the person reaches age of majority plus the standard retention period.

Frequently Asked Questions

How long should psychiatric intake notes be kept?

Most states require maintaining psychiatric records for a minimum of seven years after the last date of service for adult clients, though specific requirements vary by jurisdiction. Records for clients who were minors during treatment typically must be retained until they reach the age of majority plus the standard retention period. Check your state licensing board for specific guidance.

Can psychiatric intake notes be shared with other providers?

Psychiatric intake notes may be shared with other healthcare providers involved in the client's treatment under HIPAA's treatment provisions, though special protections apply to certain mental health information.

Psychotherapy notes (process notes kept separate from the medical record) require explicit client authorization before disclosure. Substance use disorder treatment records receive additional federal protection under 42 CFR Part 2. Best practice involves obtaining client authorization before sharing psychiatric information when possible.

What is the difference between a psychiatric intake note and psychotherapy notes?

A psychiatric intake note is part of the official medical record documenting assessment findings, diagnosis, and treatment planning. These notes are accessible to other providers and may be requested by payers.

Psychotherapy notes (also called process notes) are the provider's personal observations kept separate from the medical record and receive enhanced privacy protection under HIPAA, requiring explicit client authorization for disclosure.

How detailed should the mental status exam be in an intake note?

The mental status examination should systematically cover all major domains—appearance, behavior, speech, mood, affect, thought process, thought content, perceptions, cognition, insight, and judgment—with sufficient detail to establish a baseline and support diagnostic reasoning.

Document both positive findings (abnormalities observed) and relevant negative findings (expected abnormalities that were absent). Most comprehensive psychiatric intake mental status exams span 1-2 paragraphs, providing enough specificity to track changes over time.

Do I need to document everything discussed during the intake appointment?

Psychiatric intake notes should be comprehensive yet focused on clinically relevant information necessary for treatment planning, diagnosis, and care continuity. Focus on information directly relevant to understanding the client's psychiatric presentation, formulating diagnoses, assessing risks, and developing treatment plans. Omit tangential details that don't contribute to clinical decision-making. However, document any information that could impact safety, diagnosis, treatment response, or legal considerations.

Professional Disclaimer: This article is for informational purposes only and is not a substitute for professional clinical judgment, supervision, or continuing education. Therapists should consult current clinical guidelines, institutional policies, and legal counsel when establishing documentation practices for their specific practice setting.

Sources

American Psychiatric Association. (2022). Diagnostic and Statistical Manual of Mental Disorders (5th ed., text rev.). American Psychiatric Publishing.

U.S. Department of Health and Human Services. (n.d.). Health Information Privacy. https://www.hhs.gov/hipaa/index.html

Centers for Medicare & Medicaid Services. (2023). Evaluation and Management Services. https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched

Substance Abuse and Mental Health Services Administration. (2020). Confidentiality of Substance Use Disorder Patient Records (42 CFR Part 2). https://www.samhsa.gov/about-us/who-we-are/laws-regulations/confidentiality-regulations

American Psychiatric Association. (2016). The Psychiatric Evaluation of Adults. American Journal of Psychiatry, 173(3), 315-317.

U.S. Department of Health and Human Services, Office for Civil Rights. (2013). HIPAA Privacy Rule and Sharing Information Related to Mental Health. https://www.hhs.gov/sites/default/files/ocr/privacy/hipaa/understanding/special/mhguidance.pdf

National Alliance on Mental Illness. (2023). Mental Health Records and Your Rights. https://www.nami.org/Advocacy/Policy-Priorities/Improving-Health/Mental-Health-Records

Centers for Disease Control and Prevention. (2019). Documentation for Medical Records. https://www.cdc.gov/