Session Info

CPT code (90791 / 90792):

Session duration (min):

Modality:

In-person

Telehealth

Consent:

Informed consent acknowledged

Telehealth consent (if applicable)

Intake Narrative

Referral source:

Chief complaint:

HPI / Symptom history:

Onset / Duration:

Prior treatment (type, duration, outcome):

Current supports:

Barriers to treatment:

Additional Screening

Substance use:

Sleep quality:

Appetite / Weight changes:

Medical issues:

Current medications:

Trauma exposure:

Substance & Trauma Screen

1. How often do you have a drink containing alcohol?

Never≤Monthly2-4×/month2-3×/week≥4×/week

2. How many standard drinks do you have on a typical drinking day?

1-23-45-67-910+

3. How often do you have 6 or more drinks on one occasion?

NeverMonthlyWeeklyDaily

1. Have you used drugs other than those required for medical reasons?

Yes No

2. Do you abuse more than one drug at a time?

Yes No

3. Are you always able to stop using drugs when you want to?

Yes No

4. Have you had blackouts or flashbacks as a result of drug use?

Yes No

5. Do you ever feel bad or guilty about your drug use?

Yes No

6. Does your spouse (or parents) ever complain about your involvement with drugs?

Yes No

7. Have you neglected your family because of drug use?

Yes No

8. Have you engaged in illegal activities to obtain drugs?

Yes No

9. Have you had withdrawal symptoms when you stopped taking drugs?

Yes No

10. Have you had medical problems as a result of your drug use?

Yes No

Trauma Events

+ Add Event

Approximate Timing

e.g. childhood, age 14, 2018...

Narrative

Risk / Safety Review

1. Ideation Level

0 — None 1 — Wish Dead 2 — Nonspecific Thoughts 3 — With Method 4 — With Intent 5 — With Plan

1. Actual Attempt

Self-Injurious Behavior with Intent to Die

2. Interrupted Attempt

3. Aborted/Self-Interrupted Attempt

4. Preparatory Acts or Behaviors

5. Non-Suicidal Self-Injury (NSSI)

Most Recent Behavior

yyyy-mm-dd

Lethality (0-10)

Clinician Risk Override

No Override

Counseling - Therapy Intake Note

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