The journey towards recovery can sometimes be long and filled with obstacles, but it’s an essential first step for all patients and healthcare providers.

But sometimes, that first step can be made a lot easier. In therapy, this of course refers to the intake process, where potential clients first experience a therapist’s services. An important part of the therapeutic process, it’s when clients made their first judgments about the services they will benefit from, and the therapy methods that may be employed.

But before any interview or psychological assessment, there is another step that’s easy to brush off quickly, without giving it too much thought: the therapy intake form. This article goes deeper into this subject, explaining what this kind of form is, why it’s vital to the entire mental health process, and how you can make sure you’re doing it right in the emerging age of telehealth.

Therapy Intake Forms 101

The psychological intake form is a unique chance to get some patient details that therapists can’t necessarily acquire during intake.

Either because it may drag the process a lot needlessly (such as asking for the patient’s name, address, etc.), or because it’s vital to know pre-session, this information does have to be collected. Examples include issues the patient is facing, demographic data, and why they’re seeking therapy in the first place.

The information gathered through the intake form will be added to the patient’s file or electronic health record and stored.

What Do They Include?

There is currently no established guideline as to how these forms should be structured, however. The APA does recommend a few formats that can be edited and personalized, but at the end of the day, the mental health professional is free to structure the form as they deem fit.[1]

There are usually 5 main sections these forms should include:

  • Patient data (name, contact, etc.)
  • Insurance information
  • Medical history (including mental health)
  • Symptoms, and
  • Desired outcomes.

Some of these sections, such as the insurance information, may be included in their own form and overseen by the office or e-clinic administrator who ultimately handles this sort of information.

From a clinical standpoint, the information about the patient’s history and symptoms are the ones the therapist or telehealth professional will focus on most.

Why Are Therapy Intake Forms Needed?

Therapy intake forms are essential in almost every healthcare field, from physical therapy to speech therapy, occupational therapy, and beyond.

And there are several good reasons for this, too.

Equitable Treatment

The mental health industry has come a long way. While there is still stigma and negative attitude towards mental illnesses, in terms of available treatment, we’ve never had it so good.[2] Yet if you look closely at the effectiveness of treatments, there are a lot of gaps.

For instance, people who seek treatment for major depression will only experience positive outcomes around 40% of the time, while the others need multiple trial and error types of attempts until they will show a positive response to treatment, and others remain unaffected by it.[3][4]

So, what does this ultimately mean? Anxiety, depression, chronic stress, and other mental illnesses have been thoroughly studied, yet the people who suffer from them don’t always respond to the clinically-established treatment.

Some believe this issue calls for a more personalized form of mental health services, where all the methods employed are designed to be applicable to the individual needs of the patient, as opposed to the requirements of the mental illness they are diagnosed with.[5]

Personalized Care

But personalization cannot be done without knowing the patient first, which is where the therapy intake form comes in, together with the subsequent intake session.

Without a structured way to acquire more personal and clinical information about the patient, traditional and online treatment plans cannot be fully formed.

A patient is more than the mental issue they are struggling with. They come with a history, and this history should be disclosed to the professional who will be offering mental health services. A well-designed therapy intake form can have many benefits, both for the patient and the therapist:

  • Offering the chance to personalize the mental health treatment plan
  • Giving the therapist important insight into the patient’s history
  • Avoiding mistakes that can sometimes be fatal, especially in the case of medication (if the therapist is aware of the medication the patient is taking, then they can take that into account when prescribing additional ones).

Gathering all this patient information through intake sessions alone is inefficient, and delays the course of treatment needlessly.

Continuity of Care

Therapy intake forms are often the first step to ensuring quality, continued care for patients.

Therapy intake forms are often the first step to ensuring quality, continued care for patients

Because information from a form is added to their patient file or Electronic Medical Record (EMR), together with other assessments made by the therapist, any collected data is transferred along with it when patients change therapists.

In this scenario, patients don’t necessarily have to begin their therapeutic journey from scratch; a lot of valuable data is now on file, allowing their new therapist to continue treatment.

For example:

  • A patient’s prior diagnoses
  • Their behavioral history
  • Information about past treatments, and
  • Their current condition.

Still, it’s advised never to assume all information in older intake forms is correct.

The new therapist should revisit the initial psychological intake form to update patient information. Some of the data may not be applicable anymore, and such things can affect the treatment design.

Creating a Good Intake Form

The intake form a patient will fill out before the initial meeting with a therapist needs to be carefully designed to encompass all major information relevant for the therapist, and the overall therapeutic process.

It’s important, however, to consider what goes into the form, and what will be covered in the initial interview.

Generally, there are some common topics that need to be included:

Details

Examples

Patient Demographics

  • Full name of the patient
  • Birthdate

Contact, Payment, and Emergency Information

  • Contact information (address, phone number, email, etc.)
  • Insurance information
  • Guardian information (if the patient is a minor)
  • Referral sources (online, a friend, etc.)
  • Emergency contact information

Medical History

  • Medical history and current medical problems
  • Medications currently administered, and the name of the doctor prescribing them
  • Mental health family history
  • Past mental health services the patient may have benefited from (counseling, previous therapy, etc.) and the names of the professionals administering them
  • History of substance abuse
  • History of trauma/abuse
  • List of symptoms/feelings that the patient is dealing with (anxiety, sadness, insomnia, frustration, etc.)
  • Out-of-the-ordinary episodes the patient has previously gone through (a violent outburst at work, for instance)

Therapy or Treatment Details

  • The reason for seeking therapy
  • Desired goals/wishes of the client

Miscellaneous

  • Other information deemed relevant by the therapist.

As you can see, therapy intake forms can sometimes be long.

Creating an Intake Form: Tips

Because of this, it’s best to make them accessible to the patient before they come in for the initial meeting so that they can fill them at home, and bring them along to intake sessions.

Filling them in on location can be time-consuming, though the process can be made easier if the form offers some checkboxes at least for some of the questions.

For instance, instead of having the patient writing down their own symptoms or feelings, the question itself can have a list of possible choices the patient can cross, speeding up the process. An additional “other” box can be added for the patient to note any other symptoms not included in the list.

Though no matter how many predefined choices you offer, standard paper psychological intake forms – including informed consent forms – can still take up a lot of time. If not just filing in the information, then the entire process itself.

But luckily, with the advent of innovative e-clinic software, there are solutions to this problem.

Intake Forms in Blended Care

Patient management is a process greatly facilitated by technology.

Even if you don’t turn to specialized care management software, even simple Cloud technology like Google Drive can prove very useful to patient management.

Going Digital

Intake forms, though initially designed to exist on paper, have found a new home online, where patients can easily fill them out even on their mobile phones, before the initial visit with a mental health specialist.

For instance:

  • Therapy intake forms can be hosted on companies’ websites, especially as most practices already have a website. Potential patients scheduling a session using the practice’s appointment software can then fill the form within the same webpage.
  • Emails can also come in handy too, in case the opinion is that the intake form shouldn’t necessarily be left open for everyone to view. A patient can type in their address and get the online therapy intake form in their inbox in just a few seconds, without too much hassle.
  • With more integrated customer relationship management systems, notifications can even be sent out to remind clients to fill out their intake form prior to a first visit.

Other, more advanced systems can offer comprehensive solutions to all patient management needs, from therapy intake forms to managing appointments, sending reminders, or even automatic client billing.

Benefits of Digital Intake Forms

In the table below, we’ve summarized some of the potential benefits of digital intake forms.

Benefit

Details

Saves Time

  • Digital psychological intake forms can be easier for patients to navigate and fill out.
  • With paper-only formats, patients either need to print them or acquire them directly from the therapist’s office, which means coming in earlier to complete them.

Location-Independent

  • Digital forms are also more convenient for the patients to fill, as they can easily be written even on the move thanks to the prevalence of smartphones.

Improved Organization

  • It’s not just therapy intake forms that can be digitally stored either. When uploaded to a secure database along with any relevant BIRP or SOAP notes, practitioners can get a more holistic overview of patient progress in just a few clicks.

Hard to Forget

  • Completed forms can be automatically sent to therapists or administrators, meaning it is no longer the patient’s responsibility to physically bring them when coming for a session.
  • Digital intake forms help avoid delays when patients forget – session time is no longer required to fill and review it.

Streamlined Meetings

  • When therapists receive intake forms in advance, first meetings between them and the patient can go more smoothly.
  • Therapists can review patient data carefully at their convenience, then prepare relevant questions to gather even more case information. This all works together to create a better treatment design, greater satisfaction, and ultimately, better health engagement.

Easily Stored and Secured

  • These digital psychology tools often come with their own security measures for ensuring no unauthorized third party can access the personal information of the patient.
  • Additionally, digital data can easily be stored, updated, and, if needed, transferred.
  • Such forms can also integrate with larger EHR systems offering patient management services.
  • Data then goes directly to patient files, without the therapist or administrator having to input the data manually.

Final Thoughts

The intake process is integral in mental healthcare because it offers a shortcut for the therapist to know more information about their patients before they meet.

People are very complex, and it’s important to have a complete view of who they are. While an intake session allows them to get comfortable with the process and therapist, it’s the intake form that lets the mental health professional know how to structure this initial meeting, making it a stepping stone in the overall journey to wellbeing.

While paper therapy intake forms may still be present in some practices, specialized medical software has really improved this process, making it a lot easier for patients to go through it, while offering therapist information about new clients faster. What do you think?

References

  1. ^ APA. (2016). Mental Health Intake & Evaluation Forms. Retrieved from https://www.apadivisions.org/division-31/publications/records/intake
  2. ^ CDC. (2012). Attitudes Towards Mental Illness. Retrieved from https://www.cdc.gov/hrqol/Mental_Health_Reports/pdf/BRFSS_Full%20Report.pdf
  3. ^ Alexopoulos, G. S. (2010). Psychotherapy for late-life depression. Journal of Clinical Psychiatry, 71(6), e13.
  4. ^ Trivedi, M. H., Fava, M., Wisniewski, S. R., Thase, M. E., Quitkin, F., Warden, D., & Luther, J. F. (2006). Medication augmentation after the failure of SSRIs for depression. New England Journal of Medicine, 354(12), 1243.
  5. ^ Arean, P. A. (2012). Personalizing behavioral interventions: the case of late-life depression. Neuropsychiatry, 2(2), 135.

Related Articles

BIRP Notes: A Complete Guide on The Essential BIRP Note-Taking Format
Speech Therapy and The Apps Helping Patients Reach Their Goals