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Psychology intake template
A psychologist-oriented intake that emphasizes presenting concerns, developmental and psychosocial context, diagnostic impressions, and collaborative treatment goals—without a primary-care SOAP frame.
Template content
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Psychology Intake Note Identifying Information / Referral - Referral source, presenting request (therapy, testing, both), and patient goals for evaluation. Presenting Concerns - Current symptoms, onset, course, severity, and functional impact. - Precipitants and maintaining factors as understood at intake. History - Psychiatric/psychological treatment history and response. - Medical, developmental, educational/occupational, and family history relevant to presentation. - Substance use and trauma history as disclosed. Strengths & Supports - Coping skills, social supports, cultural/contextual factors, and prior successful strategies. Mental Status / Behavioral Observations - Appearance, behavior, mood/affect, thought process/content, cognition, insight, and judgment as assessed. Risk Assessment - Suicidal ideation, self-harm, violence risk, and protective factors; risk level with rationale. Assessment / Formulation - Diagnostic impressions and working case formulation (predisposing, precipitating, perpetuating, protective factors). - Differential considerations and need for further assessment/testing. Treatment Recommendations / Plan - Recommended modality/frequency, goals for therapy, referrals (psychiatry, testing, medical), and follow-up. - Consent, limits of confidentiality, and collaborative next steps discussed.
When to use this template
What makes the structure useful, and which visits it fits best.
Why this template works
Structural advantages for real documentation
Best for
Visit types and clinicians who use this format
- Centers psychological assessment and therapy planning over medication titration detail.
- Captures goals and modality recommendations clinicians need for episode-of-care setup.
- Includes risk and MSE elements without turning the note into a full psychiatric med visit.
- Easy to adapt for testing referrals vs psychotherapy intakes.
- 1Outpatient psychology intakes
- 2Psychotherapy episode start visits
- 3Telepsychology initial evaluations
Example output shape
Illustrative excerpt of how a visit can land in this structure. Not a real patient record—review and edit every note before signing.
Presenting Concerns 32-year-old referred for therapy after escalating social anxiety and work avoidance over 6 months. Panic in meetings; declining presentations. Sleep delayed by anticipation. Goals: reduce avoidance and stay in current role. History Prior CBT age 24 with benefit; no hospitalizations. No current psychotropic medications. Occasional alcohol socially. Supportive partner; high-achieving family context with perfectionism themes. Risk Assessment Denies SI/HI/self-harm. Risk low. Protective factors: partner, career motivation, prior therapy success. Assessment / Formulation Social anxiety disorder; rule out performance-only specifier vs broader GAD features. Formulation: perfectionism and avoidance maintain anxiety via short-term relief. Plan Begin weekly CBT with graded exposure hierarchy. PHQ-9/GAD-7 at start and monthly. Psychiatry referral deferred unless symptoms worsen. Next session: psychoeducation and hierarchy draft.
How Wavo automates this
What the product actually does with your template.
2. Record or dictate
Capture the encounter with ambient recording or dictation. Wavo structures the note using your template.
3. Review and sign
Edit with Smart Transform if needed, then export or copy into your EHR. You stay responsible for the final note.
Related templates
Put this template to work on your next visit
Start free, paste the template, and see how Wavo documents in your structure.