Comprehensive intake / biopsychosocial

Gather the history needed to formulate, plan, and assess risk — without turning the first meeting into an interrogation.

Sessions 1–2, completed across the conversation rather than read off a list.62 fields

How this document is used well

The intake has two jobs that pull against each other: collecting information, and beginning a relationship. When they conflict, the relationship wins — a patient who does not come back has given you a beautifully complete form and no treatment. Early-session alliance predicts outcome and dropout; a checklist manner is the most common way trainees damage it.

How to run it

1Open unstructured. "What brings you here now?" — then be quiet. The first three minutes uninterrupted give you the presenting problem, the idiom, and a sample of how this person organises a story.
2Follow affect before following the form. When something lands, stay with it; you can return to the sequence.
3Get one relationship episode in detail. A concrete recent interaction with a beginning, middle and end is worth more than a page of adjectives.
4Ask about risk directly and early, in plain words. Indirect phrasing does not protect anybody.
5Ask what they want to be different. Goals stated by the patient are the raw material of the treatment plan.
6Leave time. Close with what will happen next, not with the last question on the form.

In practice

"Why now?" is the single most informative question in the intake. Most people have had the problem for a long time; something changed. That something is usually the precipitant, and often the lever.

Note

Strengths are not decoration. Protective factors, prior successful coping, and existing supports carry real predictive weight in risk assessment and are the material from which relapse prevention is built. A history that records only pathology is an incomplete history.

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Title this document

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Identifying information

Client identifier*

Use a code. Never real patient data in this app.

AgePronounsGender identitySex assigned at birth (only if clinically relevant)

Ask only when it bears on care. Explain why you are asking.

Sexual orientationRace / ethnicity / cultural identity (self-described)Living situation and with whomWork / studyReferral source and route

Is attendance voluntary?

VoluntaryPressured by family/partner/employerCourt-mandated or condition of employment

A mandated client’s stated goals may not be their real ones. Name the constraint openly rather than pretending it is not there.

Presenting problem

The problem in the patient’s own words*

Verbatim where possible. Their language is data.

Why now? What changed?*Onset and course

Patient-rated severity right now

No problemWorst imaginable—

Functional impact — work, relationships, self-care, sleepWhat makes it worse; what makes it betterThe patient’s own explanation of the cause

Kleinman’s explanatory model question. A treatment rationale that contradicts the patient’s model without acknowledging it produces silent non-adherence.

What would be different if this went well?*

Mental health history

Previous treatment — what, when, with whom, and how it went

Ask what helped and what did not. A patient who has had four therapists is telling you something about either their difficulties or the field’s.

What was most and least helpful previouslyPsychiatric hospitalisationsCurrent and past psychotropic medication, including adherencePrevious diagnoses givenFamily mental health history, including suicide

Risk screen

A screen, not a full assessment. Any positive answer routes to the risk assessment form.

Thoughts of suicide in the past month?*

NoPassive — wishing not to be hereActive thoughts of killing oneself

Self-harm in the past year?

NoYes, not recentYes, within 3 months

Thoughts of harming another person?

NoYes

Does the patient feel safe where they live?

YesNoUnsure / did not answer

Any concern regarding abuse or neglect of a child or dependent adult?

NoYes

Substance use

Alcohol — quantity, frequency, heaviest recentOther substances, including prescription misuseNicotine, caffeineHistory of withdrawal, seizure, or detoxRelationship between use and the presenting problem

Ask which came first, and what happens to mood during periods of abstinence.

Medical and developmental

Medical conditions and current medicationsPhysical causes considered

Fatigue, low mood, panic and cognitive complaints all have common medical mimics. Referral for medical review is not a delay tactic; it is part of assessment.

Sleep — hours, latency, waking, qualityHead injury, seizures, neurological historyDevelopmental history and early milestones, where relevantReproductive / perinatal factors, if relevant

Relationships, family and social context

Family of origin — composition and emotional climateEarly caregiving: who was reliable, who was notCurrent close relationshipsOne recent interaction in detail*

A specific episode — what they wanted, what the other person did, what they then did and felt. This is the raw material for a CCRT or an interpersonal inventory.

Support network and communitySignificant losses and separationsTrauma history

Ask whether such experiences occurred; do not ask for detail at intake. Detailed disclosure before stabilisation and alliance can be destabilising and is not necessary for planning.

Culture, identity and circumstance

The material that makes a formulation about a person rather than a diagnosis.

Which parts of their identity feel most salient to them right nowCultural, religious or spiritual frameworks that shape how they understand thisExperiences of discrimination, exclusion or minority stress

Ask. Patients frequently do not volunteer this to a therapist whose social position differs from theirs, and its absence from a formulation is often a therapist artefact.

Material circumstances — money, housing, immigration, legal, caring responsibilities

Adversity that is real is not a distortion. Where these are the problem, practical help may outrank any psychotherapy.

Preferred language; interpreter needed?

Strengths and resources

Strengths, capacities, and what this person is good at*A hard thing they have got through before, and howWhat matters to them; what a good life would look likeReasons for living / what keeps them going

Protective in its own right, and directly usable in a safety plan.

Clinician impressions

How was it to be with this person? What did they pull for in you?

Your own reaction in the first meeting is data — often the earliest available sample of what happens in this person’s relationships.

Estimated strength of the beginning alliance

Wary / absentStrong and easy—

Provisional diagnostic impression, with differentialFirst-pass formulation in two sentencesPlan, referrals, and what happens next*

8 required fields outstanding: Client identifier; The problem in the patient’s own words; Why now? What changed? …

Educational use only

Praxical.Psych is a teaching tool. It is not medical, clinical, psychological or legal advice, not a diagnosis, not treatment, not supervision, and not a credential. Nothing here creates a clinician–patient or solicitor–client relationship. Every patient, case, transcript and simulated session is fictional. Clinical and legal requirements vary by jurisdiction and change over time — verify anything that bears on a real decision against your own regulator, statute and current professional guidance, and consult a qualified professional.

Do not enter real patient information. If you or someone else is in crisis: US & Canada 988 · UK & Ireland 116 123 · Australia 13 11 14 · elsewhere findahelpline.com · immediate danger, your local emergency number.

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