First session intake and history taking: template, structure and example

History taking, or anamnesis, is gathering the client's story and the story of their problem during the first session (what brings them, since when, in what context, with what background). The first session note brings this information together and adds the psychologist's first observations and the framework offered for the work ahead.

This template is for psychologists seeing a new client, in private practice or in an institution, whatever their approach. The history is often gathered over one or two sessions. Write the note right after, then add to it as sessions go on. It becomes the starting point of the record and a reference for measuring change.

What the intake is for

The intake gives you an overview before you start working. It lets you check that the request fits your practice, spot anything that needs a referral (medical opinion, emergency, another specialty) and choose a suitable framework. Without it, you risk working on the stated reason while missing something important, such as current medication, a recent bereavement or alcohol use.

When to use it

• At the first and often the second session with a new client.
• When resuming therapy after a long break.
• When a colleague refers a client, to complete what was passed on.

The framework

The French code of ethics for psychologists (updated in 2021) sets several useful reference points from the first session.

• Consent. The psychologist seeks the free and informed consent of the people who consult them (article 9). Explain what you offer, the length, the fee and how you take your notes.
• Professional confidentiality. It covers everything you learn through your work, what you are told as well as what you see, hear or understand (article 7). Also explain its limits if someone is in danger.
• Minors. The psychologist seeks the authorisation of the legal guardians, in line with parental authority (article 11).
• Keeping notes. Notes and data are filed and archived in a way that protects privacy (article 23).

Clients have a right to access the data that concerns them (article 15 of the GDPR, explained by the French data protection authority, CNIL). When the note is added to a record in a French healthcare facility, article L1111-7 of the Public Health Code applies. Information gathered from third parties who are not involved in care, or that concerns those third parties, cannot then be disclosed. In every case, anything you report about a relative should be useful to the therapy and written without judgement.

The structure, section by section

1. Administrative details

Name, date of birth, contact details, emergency contact if the client wishes, GP, referrer. Date and length of the session.

2. Request and reason for consulting

Who is asking, and for what. Quote one sentence in the client's own words, then rephrase the request. Note whether the step is personal, suggested by someone close or required.

3. History of the current problem

Onset, circumstances, course, frequency, what makes it worse and what helps. What the client has already tried and how it went. The impact on sleep, appetite, work and relationships.

4. Psychological and psychiatric history

Previous therapy (with whom, for how long, why it ended), hospital admissions, past and current treatment, suicide attempts.

5. Physical health and substance use

Illnesses, pain, medication, sleep. Alcohol, tobacco, cannabis, other substances, gambling, screens. Ask simply and directly, and note the answer as given.

6. Personal and family history

Childhood, schooling, significant events, losses, breakups. Family of origin and any known family history. Stick to what sheds light on the request.

7. Current situation

Housing, relationship, children, work or studies, finances, social circle. A recent event often explains why the client is coming now.

8. Resources

People the client can rely on, activities that help, what they have already been through and how. This section guides the work as much as the difficulties do.

9. Clinical observations

Presentation, rapport, reported mood and observed affect, speech, coherence. Note what you see, in plain words.

10. Risk assessment

Thoughts of death or suicide, plan, means, past attempts, violence experienced or committed. The consensus conference published by the French health authority (HAS) encourages asking directly about suicidal thoughts. Note the answer and what you did.

11. Initial hypotheses

Your provisional understanding, phrased tentatively, according to your approach. Hypotheses will be revisited.

12. Framework offered and next steps

Goals discussed with the client, frequency, expected length, fee, any referral (GP, psychiatrist, assessment), date of the next appointment.

Filled-in example

Fictional client. All details are invented.

Administrative. Mrs L., 34. Referred by her GP. First session, 50 minutes, in person.

Request. "I can't sleep anymore and I cry over nothing." Personal step, encouraged by her GP. She wants to "understand what is happening" and get her energy back.

History of the problem. Difficulty falling asleep for four months, waking around 4 am. Fatigue, irritability, loss of interest in running, which she used to do every week. The client links the onset to a reorganisation of her department and a new manager. Tried herbal teas and cut down on coffee, with no clear effect.

Background. Six months of therapy with a psychologist at 22, after a breakup, found helpful. No hospital admission. No psychotropic medication. No suicide attempt.

Health and substance use. No known illness. Two glasses of wine every evening for three months "to unwind", compared with one or two a week before. No other substances.

Personal history. Elder of two children. Parents separated when she was 12. Describes a childhood "where you had to be sensible". Did well at school, studied management.

Current situation. In a relationship for six years, no children. Management controller in a medium-sized company. Has been seeing her friends less over the past few months.

Resources. Supportive partner. A close friend she confides in. Positive experience of previous therapy.

Observations. Well presented, warm rapport. Describes her mood as "flat". Sad affect, tearful when talking about work. Clear, organised speech.

Risk. Asked directly. No suicidal thoughts. Says she has sometimes thought of "disappearing for a few days", with no thoughts of death. No sign of danger.

Hypotheses. Exhaustion linked to the work context, possibly reinforced by high self-expectations. Increased alcohol use to monitor. A depressive component to be assessed with the GP.

Framework. Two goals discussed, sleeping more regularly and understanding what is draining her at work. Weekly sessions, review at the eighth session. Letter to the GP offered and accepted by the client. Next appointment in one week.

Common mistakes

• Turning the session into an interrogation and leaving little room for the client's story.
• Not asking about suicide for fear of "putting the idea in their head".
• Forgetting current medication and substance use.
• Writing interpretations as facts, such as "emotional deprivation" with nothing observed to support it.
• Noting intimate details about relatives that add nothing to the therapy.
• Not writing down the agreed framework (frequency, fee, goals), which makes reviews harder.
• Never updating the intake when new information emerges.

Save time with Delta

Delta is the clinical assistant for mental health and allied health professionals. During the first session, Delta transcribes what is said. You can also dictate your observations after the session, or add written notes. Delta then generates the session report (short summary, detailed summary, topics for the next session), taking into account your profession and approach, and updates the client record with a summary of the therapy and the goals being tracked. Data is hosted in France with an HDS-certified provider, the client's name and identifying details are pseudonymised before the AI, no audio file is kept and data is never used to train a model. Learn more about Delta.

Read also

• Crisis session note and suicide risk assessment
• Mental status examination, template and example
• Psychologist's letter to the GP
• Note-taking software for psychologists
• All clinical document templates

Sources

• French code of ethics for psychologists, 2021 update (articles 7, 9, 11 and 23)
• HAS (ANAES), The suicidal crisis: recognition and care, consensus conference, 2000 (in French)
• CNIL, the right of access to your data (in French)
• Service-public.fr, access to medical records (in French)