The psychiatric intake: the questions that build a defensible evaluation, and how to document the answers

By Selam Koch, PMHNP-BC, founder of OneStep Scribe and practicing psychiatric nurse practitioner. Published July 2026.

The intake is the one visit that lives in the chart forever. Every progress note that follows references it, borrows from it, and is measured against it. When a diagnosis is questioned two years later, when a payer audits the course of treatment, when a covering clinician picks up your patient in a crisis, the intake is the document they read first. A thin intake makes every note downstream harder to defend. A thorough one carries the whole chart.

An intake also has a different job than a follow-up. A follow-up updates a known story. An intake builds the story from nothing: it establishes the differential, the baseline, the risk picture, and the rationale for the plan in a single sitting. That is a great deal to gather and a great deal to document, and the two tasks compete for your attention in the room. This guide walks the domains a complete intake covers, the questions that actually pull useful data out of each one, and what to capture in the note so the evaluation holds up when someone reads it later.

What a complete intake covers

Whether you use a structured template or a free interview, a defensible psychiatric evaluation touches every one of these domains. The value is not in the headings; it is in whether each section contains real, patient-specific data or a blank that a reviewer will notice.

Domain	What it establishes
Chief complaint and HPI	Why the patient is here, why now, and the narrative of the presenting problem.
Past psychiatric history	Prior diagnoses, treatment, hospitalizations, and self-harm history.
Medications and trials	What has been tried, at what dose, for how long, and why it stopped.
Substance history	Current and past use of alcohol, nicotine, and other substances.
Medical history	Conditions and medications that shape the differential and prescribing.
Family psychiatric history	Heritable risk, and family response to specific treatments.
Social and developmental history	The context that explains onset and shapes the plan.
Risk assessment	Suicidal and homicidal ideation, access to means, prior attempts, protective factors.
Mental status exam	Your direct observation of the patient today.

Chief complaint and HPI

Open with the patient's own words: "What brings you in today?" Then ask the question that separates a narrative from a list: "Why now, and not a month ago?" Onset, course, duration, triggers, prior episodes, and functional impact all flow from there. Ask what a bad day looks like, what changed at home or work, and what the patient hopes treatment will do.

In the note, quote the chief complaint, then write an HPI that reads as a story: when it started, what it looked like, what made it better or worse, how it touched sleep, work, and relationships, and why the patient is presenting today. Include the pertinent negatives you screened for.

Why this matters: "Reports depressed mood, poor sleep, low energy, poor concentration" is a symptom list a template could have generated. "Symptoms began six weeks ago after a layoff; sleep dropped to four hours, she stopped answering calls from friends, and she came in because her partner said she 'wasn't herself anymore'" is a narrative that justifies a diagnosis and a plan. The reviewer can tell the difference instantly.

Past psychiatric history

Ask when the patient first saw anyone for mental health, who has treated them, and what the working diagnoses have been. Ask specifically about hospitalizations: how many, roughly when, voluntary or involuntary, and what precipitated each one. Ask directly about prior suicide attempts and self-harm, and about any history of mania or psychosis, because those answers change the differential more than almost anything else.

Document it chronologically, with each hospitalization tied to a rough date and a reason. A prior involuntary admission for a manic episode is not a detail; it can be the whole diagnosis.

Medications and trials

The useful questions here are about adequacy, not just names. For each prior medication ask the dose, how long it was taken, whether it helped, and why it stopped: side effect, lack of benefit, cost, or lost access. Include over-the-counter agents and supplements, past and present.

Document an adequate-trial history, not a word bank. "Failed sertraline" tells the next prescriber almost nothing. "Sertraline titrated to 150 mg for eight weeks with partial response, discontinued for sexual side effects" is the rationale for the next choice, and it is the line a reviewer needs to see before agreeing that a switch was reasonable.

"Tried everything and nothing worked" is not a medication history. Without doses and durations, you cannot tell an inadequate trial from true treatment resistance, and neither can anyone reading the chart. Pin down at least the agents, the highest doses reached, and roughly how long each was taken.

Substance history

Ask about alcohol with numbers, not adjectives: how many days a week, how many drinks on those days, and the most in a single day. Ask about nicotine, cannabis, stimulants, opioids, and benzodiazepines (prescribed and otherwise), and about caffeine, which is easy to forget and clinically relevant. Ask in a matter-of-fact tone, because judgment in your voice shrinks the answer. Screen further when indicated, and ask about withdrawal history.

Document each substance with a pattern, or an explicit negative. "Denies alcohol, nicotine, and other substance use" is a documented screen. A blank substance section is a gap a reviewer will read as "never asked."

Medical history

Ask about active conditions with psychiatric weight: thyroid disease, cardiac and neurologic problems, hepatic and renal function, head injury, and seizures. Ask about pregnancy status and plans for anyone who could become pregnant, about sleep and pain, and about all allergies. Ask who the primary care provider is.

Capture the conditions and medications that shape diagnosis and prescribing, plus allergies. An untreated thyroid disorder or a QT-prolonging medication belongs in the intake, not discovered later.

Family psychiatric history

Ask whether any blood relatives have carried psychiatric diagnoses, struggled with substances, been hospitalized, or died by suicide. Then ask a question clinicians often skip: "Did anyone in your family do especially well, or badly, on a particular psychiatric medication?" Family response is real-world data on a shared genome.

Document specific relatives and specific conditions. A family history of bipolar disorder or completed suicide is not a footnote; it reshapes the differential and raises the floor on your risk assessment.

Social and developmental history

Ask about the living situation, relationships and supports, work or school, and the stability of housing and finances. Ask about legal history, about trauma (carefully, and without forcing detail), and about current stressors. Ask about developmental milestones when the presentation calls for it, and about culture, identity, and spirituality where they bear on care. Ask, plainly, whether there are firearms in the home.

Document the social context that explains why symptoms emerged now and that shapes a realistic plan, along with the safety-relevant facts: access to means and the supports the patient can actually lean on.

The risk assessment: what must appear, and how to document a negative screen

Every psychiatric intake must contain a risk assessment, and it must be more than a checkbox. Ask directly, and ask the same way each time so nothing is skipped:

Suicidal ideation: "Have you had thoughts that life is not worth living, or thoughts of ending your life?" If yes, follow with frequency, intensity, plan, intent, and any preparatory behavior.
Homicidal ideation: thoughts of harming others, with the same follow-up when present.
Access to means: firearms in the home, stockpiled medication, other lethal means.
Prior attempts: the single strongest predictor of future risk. Number, method, approximate dates, medical severity, and what care followed.
Protective factors: reasons for living, dependents, supports, engagement in treatment.

A negative screen is only defensible if it names what you asked and pairs the patient's answer with your reasoning. "Denies SI/HI" alone is thin; it does not show what was actually assessed. Anchor the negative to the specifics, then state the clinical judgment that follows from them.

Documented risk assessment (intake, negative screen)

Denies current suicidal or homicidal ideation, intent, or plan. Denies any history of suicide attempts or self-injurious behavior. No firearms in the home; no stockpiled medication. Identifies her two children and her faith community as reasons for living and reports a supportive partner. No command hallucinations. Based on the absence of ideation, no prior attempts, limited access to means, and strong protective factors, assessed at low acute risk of harm to self or others. Risk to be reassessed at each visit.

Why this holds up: it records the questions and the answers, not just a conclusion. It names the protective factors and the access-to-means finding that support the "low acute risk" judgment, so a reviewer can see the reasoning rather than take it on faith. And it closes with a forward commitment to reassess, which is exactly what makes a single-visit risk statement part of an ongoing standard of care. For the deeper version of this section, the suicide risk assessment documentation guide works through positive screens as well.

A compact intake, documented

The patient below is fictional. This is not a full evaluation; it is a condensed illustration of how the domains read when each one carries real data instead of a template default.

Intake evaluation (excerpt, fictional patient M.T.)

Chief complaint: "I can't keep it together at work anymore."

HPI: 34-year-old woman, no prior psychiatric care, presenting with eight weeks of low mood, initial insomnia, anhedonia, and difficulty concentrating that began after a demotion. Reports missing three days of work in the past two weeks and withdrawing from friends. Denies discrete periods of elevated mood, decreased need for sleep, or increased goal-directed activity. Came in now because a supervisor raised a formal performance concern.

Past psychiatric history: One episode of depression at age 22 treated by primary care; no hospitalizations; no prior self-harm or attempts.

Medications and trials: Fluoxetine years ago, dose and duration uncertain, "helped for a while," stopped when she moved and lost her prescriber. No current psychiatric medication.

Substance history: Alcohol two to three drinks on weekends; denies nicotine, cannabis, and other substances; two cups of coffee daily.

Medical history: Hypothyroidism on levothyroxine, last TSH unknown; no known drug allergies.

Family psychiatric history: Mother with recurrent depression who "did well on an SSRI"; maternal uncle with alcohol use disorder. No known family history of bipolar disorder or suicide.

Social history: Lives with her partner, employed, stable housing; no legal history; no firearms in the home.

Risk: Denies SI/HI, intent, or plan; no prior attempts; strong supports. Low acute risk; reassess each visit.

Why this holds up: the pertinent negatives in the HPI (no elevated mood, no decreased need for sleep) actively rule out the differential, the medication line records an inadequate prior trial that justifies re-treatment, and the untreated thyroid status is flagged for follow-up before prescribing. The family history of a maternal SSRI response is a genuine data point for the plan, not a decoration. Every section reads as this patient, which is precisely what a cloned intake cannot claim. Where this sits inside a diagnostic evaluation for coding purposes is covered in 90791 vs 90792.

The intake failures reviewers catch

Copy-forward from a template. An intake with generic HPI language, default review-of-systems text, and an MSE identical to your last three patients is the fastest tell in a records review. It undercuts every accurate line around it, because the reviewer can no longer trust that any section was written from this visit.
Risk not documented. An intake with no risk assessment, or a bare "n/a" in the risk field, is the single most consequential gap. Suicide screening at the initial evaluation is expected practice, and its absence is what plaintiff attorneys and quality reviewers look for first.
No substance or family history. Blank substance and family sections read as "never asked." Both domains carry diagnostic and safety weight, and an empty field cannot be defended as a negative screen. Document the negative explicitly.
An HPI that is a symptom list with no narrative. A string of checked symptoms with no onset, course, trigger, or "why now" does not support a diagnosis; it just restates the checklist. The progress note guide shows how the same narrative discipline carries through every note after the intake.
An MSE that does not match the story. A distressed HPI paired with a boilerplate "euthymic, full range" exam tells a reviewer that at least one section was not written from the room. The mental status exam guide covers how to keep the exam specific and consistent with the rest of the evaluation.

Frequently asked questions

How long should an intake note be?

Longer than a follow-up, because it is building the entire record, but length is not the goal. A defensible intake is complete across every domain and specific within each one. Ten thorough sentences of real data beat three pages of template boilerplate, and a reviewer measures the note by what it establishes, not by its length.

Do I have to document a risk assessment if the patient clearly is not suicidal?

Yes. The whole point of documenting a negative screen is to show that risk was assessed and found low on this date, with your reasoning attached. A patient who looks low risk today can present differently next month, and the intake is where the baseline judgment and the commitment to reassess are recorded.

What do I do when the patient is a poor historian?

Document that. Note the limits of the history, where the information came from (the patient, a family member, prior records), and what remains to be confirmed. "History limited by the patient's difficulty recalling dates; prior records requested" is honest, defensible, and far better than a confident-sounding narrative built on uncertain facts.

Can I finish the intake note later?

Some documentation always happens after the visit, but the intake is the worst note to reconstruct from memory hours later, because it has the most detail and the least prior context to lean on. The closer the note is written to the encounter, the more accurate the substance history, the medication timeline, and the risk picture will be. Same-day completion is the defensible standard.

Can an AI scribe help with the intake?

The intake is where an ambient scribe earns its place, because it is the longest, most detail-dense visit you document. OneStep Scribe listens to the evaluation and drafts the note across every domain covered here: a narrative HPI with the pertinent negatives, a medication history with the doses and durations that were actually discussed, an explicit substance and family history, a structured risk assessment, and an MSE built from what was observed in the room. The draft is organized the way an evaluation should read, with each section populated from this specific conversation rather than a template.

What it does not do is replace the clinician. You still ask the questions, you still make the risk judgment, and you review and confirm every section before you sign. A drafted intake you verified in a couple of minutes is a fuller, more defensible record than one typed from memory at the end of a long day, and it is built from the visit rather than from last patient's boilerplate.

The intake structure above is exactly what OneStep Scribe drafts from the visit, domain by domain.

OneStep Scribe is an AI scribe built for behavioral health clinicians. It listens to the evaluation and drafts the complete intake note, including a narrative HPI, a real medication and substance history, and an explicit risk assessment, for your review and signature. Every account is NPI-verified.

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This article is educational and reflects one clinician's documentation approach. It is not clinical, legal, or billing advice for any specific patient, and it does not guarantee any outcome or reimbursement. The patients described are fictional. CPT is a registered trademark of the American Medical Association. Always verify requirements with current clinical guidelines, your payers, and your compliance advisors.