Template intake notes
1. Register complaint(s) - since when, acute/non-acute, precipitating factor:
2. Discuss ROM score and outcome with the client:
3. Help question/goal. What does the client specifically want to achieve with therapy in a measurable, acceptable, and realistic way, and within what timeframe?
4. Initial impression of the client and how to establish contact:
5. Current living and work situation - married/single/divorced, children, employment/benefits/sick leave (since when), housing situation:
6. Relevant personal and developmental information, family of origin, possible traumas:
7. Social network and family policy:
8. Previous interventions: if so, what was the result?
9, Current interventions:
10. Assessment of suicide risk - do they have suicidal ideas, abnormal experiences, hopelessness, severe substance abuse, aggression?
11. Are there indications that the client's situation or condition poses risks to children?
12. Health, somatic complaints, medication (since when, dosage, effect), and other relevant medical information:
13. Substance use:
14. Physical activity, sports, relaxation, sleep:
15. DSM-5 descriptive diagnosis:
16. Type of therapy, prognosis, duration of treatment, proposed profiles:
17. Is there a match with the therapist? Comments and specifics:
18. Notes from the 2nd intake with the lead clinician:
19. Is there a multidisciplinary guideline, generic module, or care standard applicable? If so, is it being followed? If not, what is the motivation for deviating from it?
20. Has the client's ID been verified?