Writing Up the Intake Interview
The ability to write up a clear, comprehensive, and professional intake evaluation report is a top skill for seasoned mental health professionals. However, this task often seems overwhelming to the beginning clinician, who also is facing the challenges of learning other basic interviewing and therapy skills. But imagine a clinician who conducts a whole course of treatment without formally documenting anything about why clients came for services, what problems they initially had, and what treatment recommendations and goals were established. How could this practitioner justify the type of treatment provided and gauge whether or not treatment was successful? Indeed, practices with limited documentation cannot survive in today's climate of managed health care organizations, professional accountability, and client rights. No matter what clinical specialty or type of setting in which therapists work, they most likely will be responsible for writing at least some form of an intake report. Historically, however, many psychology training programs have not provided formalized classroom training in professional report writing. Rather, students learned to write intake reports through informal means: studying old intake reports in their clients' charts or borrowing "model" reports from more experienced students or teachers. This chapter assists therapists in report writing, and offers practical and explicit guidelines to help them prepare well-written and thorough intake reports.