Clinical note best practices
Summary
When creating effective intake forms, include essential documents such as informed consent, privacy notices, financial agreements, risk screenings, and client demographic and insurance information.
Use thoughtful clinical documentation design to make intake paperwork accessible, mobile-friendly, easy to understand, and simple for clients to complete.
Ensure intake forms remain compliant by regularly reviewing legal, ethical, payer, and state-specific requirements, including HIPAA, Good Faith Estimates, mandated disclosures, and informed consent procedures.
Clinical documentation design can feel overwhelming. When setting up a practice, it can be hard to create intake paperwork that balances gathering sufficient client information with making forms accessible and fulfilling your ethical, legal, and payer obligations.
In this guide, we cover creating effective intake forms, what information is essential, how to make forms user-friendly, what language to use, and when to update forms.
What information is essential?
When creating effective intake forms, clinical documentation design should balance collecting essential administrative, clinical, and billing information with keeping paperwork manageable for clients. Include information to build a detailed picture of the client as part of the biopsychosocial assessment.
The essential intake documents to include when creating effective intake forms are:
Client identifying information: Include the client’s name, date of birth, gender, pronouns, preferred name, language, contact information, accessibility needs, and emergency contact.
Intake form: This can be as brief as the client’s reason(s) for seeking therapy, or detailed with questions about their educational background, family history, mental health treatment history, psychological and physical health concerns and diagnoses, stressors, supports, strengths, client identities, treatment goals, current symptoms, medication history, substance use screening information, living situation, social support, occupation and work information, religious, cultural, or spiritual beliefs, and other providers treating the client.
Insurance information: Include the name of the client’s primary insurance (and secondary, if applicable), ID number, group number, along with a copy of the front and back of their insurance card.
Informed consent for treatment: This document should describe the nature and purpose of therapy, risks and benefits, the client’s rights, the therapist's credentials, the therapist's role, the limits of confidentiality, emergency procedures, and contact information.
HIPAA and privacy notice: Describe how records are stored and protected, the client’s rights, and when information is shared.
Good Faith Estimate of fees: Inform clients of the expected cost of services in advance to protect them from unexpected surprises.
Practice policies: Include any relevant policies, such as the privacy policy (if not included in the HIPAA notice), late or no-show policy, and termination of services.
Financial agreement: Inform clients of the fees for services, copay information, payment methods, how they will be billed, cancellation policy, and other relevant financial information.
Credit card authorization form: You should also keep a payment method on file to bill automatically after the client session.
Telehealth consent (if applicable): This notice details how telehealth works, the platform used, security measures, and other relevant information.
Mandated disclosures: When creating effective intake forms, include information about limits to confidentiality in relation to risk of harm, abuse, or neglect of vulnerable populations. Certain states also require additional disclosures. For example, some states require disclosure of how to file a complaint about the clinician with the relevant licensure body.
Risk-screening form: Ask questions to assess whether the client is, or has recently, experienced suicidal ideation. This can also help determine the level of care needed and whether it falls outside the clinician's scope of practice.
Some practices also include measurement-based screening tools, like the Patient Health Questionnaire (PHQ-9), Generalized Anxiety Disorder-7 (GAD-7), or suicide screening questions like Ask Suicide-Screening Questions (ASQ) or the Columbia Suicide Severity Rating Scale.
If the client has already informed the clinician of a prior diagnosis of post-traumatic stress disorder, they may be asked to complete the PCL-5.
What about electronic formats?
Most electronic health record (EHR) systems allow you to easily send intake forms to clients for completion before their intake.
You can also set up electronic reminders to ensure the paperwork is completed with enough time for the clinician to review the information, usually at least 24 hours before the intake appointment.
Tips for creating effective intake forms
Intake paperwork can be overwhelming for any client. It’s anxiety-inducing enough to meet a new therapist, never mind adding a bunch of paperwork on top of ever-expanding to-do lists.
However, this is an opportunity to start building your relationship with the client by normalizing the intake process, validating that the volume of paperwork can be overwhelming, and explaining why the paperwork is necessary for them to make an informed decision to proceed with treatment. You can also underscore how you are here to support them through that process.
Additional clinical documentation design strategies for creating effective intake forms include:
Personalize the process: Ask the client about their specific accessibility needs, such as if they prefer large print or paper copies, and if they need support to complete their intake paperwork. Offer a telephone number or email address for them to contact you if they need assistance.
Digitize your intake process: Use an EHR that stores all your intake paperwork and sends the relevant forms to your client with a single click.
Provide accessible formats: To support accessibility and ease of completion, provide intake forms in user-friendly formats, which we explain further below.
Automate where possible: Set automatic reminders that remind the client if they have outstanding paperwork, and allow online scheduling.
Prioritize completed paperwork: Some therapists allow clients to come to the session, but may request that they complete the paperwork before the session begins. Others may conduct a shorter assessment, whereas others will reschedule.
Provide support: Checking in with the client or having a team member reach out to them can make the difference between completed and incomplete paperwork.
How to make forms user-friendly
Thoughtful clinical documentation design can reduce barriers to care and improve the client experience from the first point of contact.
Keep these ideas in mind to create effective intake forms:
Normalize accessibility by offering a range of formats from the start. For example, when booking the client for intake, offer multiple formats, including digital, print, and the option to complete them verbally.
Use EHRs that are compatible with both mobile and desktop devices, as many users will complete them on their smartphones.
Make forms visually accessible by using clear, sans-serif fonts (such as Arial or Calibri) in at least size 12, with high contrast and large text options.
Lay out policy information in brief sections, with headers, bullets, and plenty of white space where possible to enhance readability.
When creating effective intake forms, clearly label form fields. For example, in the contact information section, label the fields you want the client to complete for their name, address, email address, and telephone number.
Use plain English, avoiding clinical language and jargon, and aim for a 6th to 8th grade reading level. For example, “What brings you to therapy?”
If sending forms as a PDF, ensure they have fillable fields, but don’t assume the client has the software to download or convert them. Online forms may be easier to complete.
Use an accessibility reader, such as WAVE, the PDF Accessibility Checker, or WebAIM, to ensure your paperwork and website are accessible to all individuals.
How to ensure compliance
There are several ways to ensure compliance when creating effective intake forms. While all therapists are required to adhere to HIPAA requirements, other legal and regulatory requirements may vary across states, regulatory boards, and payers.
Broadly speaking, however, intake paperwork should include informed consent, HIPAA, risk, licensure information and complaint procedures, accessibility information, and a Good Faith Estimate.
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