How to conduct a therapy intake session? A detailed guide

Just like going to a new doctor for the first time can make a person feel anxious, going to a new therapist can induce a similar state of mind. This anxious state of mind may be worse for someone who is going to therapy for the first time ever rather than just changing their therapist. 

Though a doctor may examine you down to the very inside of your body, when it comes to comparing it with therapy, the latter is something that requires far more vulnerability and bravery. This is why therapy intake sessions are integral and warrant a certain amount of mastery by any mental health professional. 

Therapy intake sessions, also called initial intake interviews or assessments intake evaluations, are crucial components of the therapeutic process. These sessions are actually the first meetings between a mental health professional (therapists, counsellors, or psychologists) and their client.

The first session determines whether a person will want to continue to take therapy from the same professional. This is why the intake sessions are of immense importance and need to be handled carefully.

What Exactly Happens in an Intake Session?

A therapy intake session usually consists of gathering information about the client, establishing a working relationship with the client, and setting the foundation for future interactions. This sounds simple enough in writing however could become difficult in practice.

To make things easier, let’s do a breakdown and look at all the steps involved in a therapy intake for further insight:

Pre Work for therapy intake Session

The preparation for a therapy intake session starts way before the session itself. Pre Work is not something that you can skip, you must carefully think through all that the session will entail and be well prepared for it. 

Paperwork

Paperwork is an integral part of the intake session. The most important part of the paperwork is signing a professional disclosure statement i.e., informed consent. The client may also need to sign and consent to a social media policy, if the therapist has one. 

A lot of health care providers also create a welcome letter that outlines one's background, methodology, contact information and other words of welcome. 

For a smooth sailing intake session it is good practice to be prepared with paperwork so you do not waste precious time from the intake session and direct it towards building a connection with your client.

Review the Client’s Background

Of course you will learn about your client as the sessions go by, as they open up and tell you about themselves. However, if they have already shared with you what is going on with them, why have they decided to come to therapy (presenting problem), you should make use of this information. 

You may also have previous notes from a therapist or a doctor of your client, in case they referred them to you, in this instance you should use this information to establish an understanding about your client. You should also use this information as a reference point, as a way to steer conversation, to build rapport. 

Prepare a Set of Questions to Ask

It is best to have thought of what you are going to discuss in the intake session to save time and for the session to go smoothly. A new client should sense that you are prepared and know what you are doing to be able to put their trust in you and to be able to open up. 

Of course the questions that you are planning to ask should be relevant and add value to the session. Here you can make use of any background information, if you have any, to tailor your discussion questions. 

Also, make sure that the questions that you are asking do not overwhelm the client. It is the intake session after all, you need to slowly build up to the tough questions and must refrain from jumping straight in. Remember to remain patient!

During the First Session

There are several sessions that you need to take care of for a successful intake session. As we have established above some of these steps need to be taken care of beforehand, while others as we will discuss below will happen during the session.

Paperwork 

You should have the formalities dealt with first so then they do not interrupt with the flow of the discussion later. 

Perhaps the most important document that your client will need to sign is the informed consent form. This document outlines the terms and conditions of therapy, including confidentiality, payment policies, and some details about your approach. The client needs to sign this form to acknowledge their understanding and agreement. 

Other important paperwork may include HIPAA (Health Insurance Portability and Accountability Act) Notice which explains privacy rights of clients and how their health information will be handled.

At this point you should also go over fee agreement or payment information. Any other information related to insurance, missed sessions and charges for cancelled appointments should also be communicated at this point.

Talk About Process

You can finally start the therapy session by giving them a walk through of how your therapy process works. You can ask your client if they have been to therapy before, if they have you can ask them about their experience. This should be followed by a segue into talking about your own therapy process, you should explain how your approach differs from their previous experience. 

Ask your client if they have any questions, at this point you can ask them what are their goals for coming to therapy.

Use Active Listening

As your client starts talking about their goals and expectations from therapy, you can start slowly and gradually asking them about their background, their family history. Remember to build the conversation up to asking them difficult questions, do not jump right into them and overwhelm your client.

You can also ask your client about the presenting problem if they appear hesitant to open up. Presenting problems is the primary reason why an individual may decide to finally go to therapy. There may be several things, a series of events, that could have preceded the presenting problem. 

However, there is likely to be one specific thing that finally pushed a person into going to therapy. The goal here should be to establish a better understanding about your client, not to force them to open up if they do not want to.

Make sure that you are employing active listening techniques throughout, these may include keeping your body turned towards the client, using open gestures to show that you are engaged and so on. Show them that you are interested, alert and listening to them carefully.

Important Information to Collect

Though the focus of the first session is to make sure the client is comfortable and to build rapport, collecting information about the client should remain an important focus of the session.

You should make sure to cover important information about your client which can be used to form a diagnosis and treatment plan for them.

This information may include basic symptoms which may include certain feelings or thoughts, which are impacting their everyday lives. These symptoms could be implicating their emotional and physical well-being, or making doing everyday tasks difficult. You should make a note of them. These symptoms will serve as an important roadmap towards a diagnosis.

Another important thing to explore in the first session is social and developmental history. Details about general social and environmental factors in a person’s life are important and could be significantly contributing to mental and emotional disruptions. You should make note of these, especially while devising a treatment plan.

Finally, another important piece of information is family history. Family’s psychiatric history can shed light on and give insight on your client. However, focus should not just be psychiatric history in the family, but also their relationship with the client. Pay attention to the client’s upbringing, their relationship with primary members of the family, medical history, family support levels, socioeconomic status and so on. 

Other Tips to Keep in Mind

Steps discussed above are crucial and incorporating them properly can lead to a successful intake session. The significance of therapy intake sessions is paramount, they serve as the foundation upon which the therapeutic relationship is built.

You should try to do justice to your client by carefully following the steps discussed above; however at the same time it is important to remember that your client needs to meet you halfway. The client should be receptive, and open to guidance. Your job is to convince them by trying your best however, it is important to not take things personally if the client does not return after the intake session. 

Furthermore, it is important to remember that to be able to continue to treat a client you should have relevant experience and expertise in treating patients with similar diagnosis. If there is a mismatch between your qualification and their potential diagnosis and consequent treatment plan, refer them to the relevant expert.

Conclusion

The steps discussed above are crucial and should be kept in mind to be able to master therapy intake sessions. therapy intake sessions are the foundation upon which your relationship with your client will be set, this is why it is important that they go well.

For a person to return at all to you, the session needs to go smoothly. Steps discussed above is all that you need for that. Of course you must modify, add or remove certain steps, depending on your client’s specific need. 

These sessions demand a careful balance of preparation, thoughtful communication, and active listening. The importance of this initial encounter cannot be overstated, as it lays the groundwork for a trusting, collaborative relationship that is crucial for effective therapy. 

The steps outlined in this guide, when applied with diligence and sensitivity, serve as a roadmap to mastering the art of therapy intake sessions. Success in these initial encounters not only facilitates a client's return but also, more importantly, sets the stage for meaningful and impactful mental health treatment. Each client is unique, and the flexibility to adapt these steps to meet individual needs is key to success.