A psychology intake assessment is the structured first-session record that establishes why a client is presenting, their relevant history, risk and current functioning, plus a working formulation and plan. In Australia it also carries two compliance jobs: validating the Medicare referral before you claim, and giving the client the privacy notice required at collection.

Most intake templates online are written for the United States, where the organising logic is insurance authorisation and medical necessity. Australian practice runs on a different spine: the referral, the Better Access service caps and the Privacy Act shape what your intake has to capture. Getting those wrong is less a clinical problem than an unclaimable session or a privacy complaint.

What is a psychology intake assessment?

The intake assessment is the first substantive clinical contact and the document it produces. It does four things at once: gathers the information you need to understand the presenting problem, screens for risk, produces a provisional formulation, and sets the baseline every later progress note is measured against.

It is not the same as an intake form. The form is the client-completed paperwork (demographics, consent, history checklists) that arrives before the session. The assessment is your clinical work on top of it. Treat the two as one thing and you end up with a file full of client-reported data and no clinician reasoning, which is the gap that shows up when someone asks how you arrived at a diagnosis.

What should a psychology intake assessment include?

There is no single mandated structure, so cover the domains a reasonable colleague would expect to find:

Presenting problem: what brought them in now, in their words, plus onset, duration, frequency, severity and what has changed recently.
History of the presenting problem: previous episodes, prior treatment and what helped or did not.
Relevant background: developmental, family, medical, medication, substance use, trauma, education and occupational history, culture and identity, current supports.
Current functioning: work or study, relationships, sleep, appetite, daily activities.
Risk: suicidal ideation, self-harm, harm to others, neglect, family violence, child safety. Record what you asked and what they answered, not just a rating.
Mental state examination: appearance, behaviour, speech, mood and affect, thought form and content, perception, cognition, insight and judgement.
Standardised measures: whichever you administered, with scores and dates so change is trackable.
Formulation: your explanatory account, not a restatement of symptoms.
Provisional diagnosis or diagnostic impression.
Goals and plan: agreed goals, proposed modality, session frequency and planned length of the course of treatment.

A widely used scaffold for the formulation is the five Ps (presenting, predisposing, precipitating, perpetuating and protective factors). Our guide to writing a case conceptualisation covers the main models, and the therapy treatment plan guide picks up where the intake leaves off.

What do you need to check about the Medicare referral at intake?

This is where a first session most often goes wrong administratively, and where US templates cannot help.

Under the Better Access initiative, eligible patients can claim a Medicare benefit for up to 10 individual and 10 group therapy mental health treatment services per calendar year (1 January to 31 December), and must have either a mental health treatment plan or a psychiatrist assessment and management plan in place, according to the Department of Health, Disability and Ageing. The count resets on 1 January. It is not a rolling twelve months from the first session, which is a common and expensive misreading.

The MBS explanatory note on referral requirements for Better Access treatment services sets out three things your intake should record:

The referral pathway. Referrals must come from a GP or prescribed medical practitioner at the practice where the patient is enrolled in MyMedicare, or from their usual medical practitioner managing them under a mental health treatment plan, or under a Psychiatrist Assessment and Management Plan, or on direct referral from a psychiatrist or paediatrician.
The number of services in this course of treatment. The note states the maximum service limits plainly: "Initial course of treatment - a maximum of 6 individual services", with a subsequent course covering the remaining services up to the patient's cap of 10 per calendar year.
What you did if the referral was silent or wrong. If the referring practitioner does not specify the number of services, or specifies a number above the maximum allowed, the note is explicit that "the eligible allied health professional must contact the referring practitioner to determine the required number of services required". Only if the referrer cannot be contacted may you use clinical judgement within the caps.

That third point is an active obligation, not paperwork etiquette, and the only durable evidence you met it is a line in the intake record: who you contacted, when, and what was confirmed. Add a referral block at the top of your template covering referrer name and provider number, referral date, pathway, plan type, services specified, and services already used this calendar year.

What privacy notice do you have to give at intake?

Intake is when you collect the bulk of a client's health information, which makes it the moment Australian Privacy Principle 5 bites.

APP 5.1 requires an entity that collects personal information to take reasonable steps either to notify the individual of certain matters or to ensure they are aware of them, at or before the time of collection, or as soon as practicable afterwards. The OAIC's APP 5 guidelines list those matters: your identity and contact details, the fact and circumstances of collection, its purposes, the consequences if the information is not collected, who you usually disclose to, how the client can access and correct their information, how to complain, and whether you are likely to disclose overseas.

Two practical consequences follow. First, the collection notice belongs in the intake pack and should be acknowledged in the record, not buried in a website privacy policy the client never opened. Second, a longer intake form is not a safer one. Health information is sensitive information under the Privacy Act, and APP 3.3 permits collecting it only where the collection is reasonably necessary for your functions and the individual consents, unless an exception applies. Fields you never use are not neutral: they are information you must hold, secure and eventually disclose if the client requests access, with retention obligations running from there. We cover those in how long to keep clinical records in Australia.

Professional obligations sit alongside the privacy ones. The Psychology Board of Australia's Code of conduct sets the standards on informed consent and confidentiality that your intake process should be able to demonstrate.

Which intake interview questions are worth asking?

Good intake questions open broad and narrow as you go. A workable sequence:

"What made you decide to get in touch now?" The word now surfaces the precipitant rather than the diagnosis.
"What does a bad day look like from waking up to going to bed?" Better functional detail than a severity scale alone.
"What have you already tried, and what did it change?" Establishes prior treatment response.
"Who knows you are here, and who is in your corner?" Supports and disclosure boundaries in one question.
"In the past two weeks, have you had thoughts that you would be better off dead or of hurting yourself?" Ask risk directly and record the wording.
"If therapy went well, what would be different in six months?" Turns the presenting problem into a measurable goal.
"Is there anything I have not asked about that I should know?" Catches what the structure missed.

How does the intake assessment feed the report you owe the referrer?

This is the strongest argument for writing a thorough intake rather than a thin one. The MBS descriptor for item 80110 requires that "on the completion of the course of treatment, the eligible psychologist gives a written report to the referring practitioner on assessments carried out, treatment provided and recommendations on future management of the patient's condition".

Note the first item in that list: assessments carried out. The report you are obliged to send is partly a report on your intake. Write a genuine assessment at session one and you can generate it from the file. Write three lines and a diagnosis and you will reconstruct it from memory months later, which is slower and less defensible. The same file feeds your ongoing mental health progress notes and any psychological assessment report you produce.

How do you write it up without losing the session to typing?

Intake is the longest note you will write for a client, and it competes with rapport in the session where rapport matters most. Structure the template so the compliance fields (referral block, collection notice acknowledgement, risk) are quick to complete, leaving your attention for the narrative. Take history from the client-completed form rather than re-asking it, and use session time to test and extend it. Write the formulation the same day.

PractaLuma is AI-native practice management software for Australian mental-health practices, and intake is one of the workflows it is built around: structured intake and triage, clinical documentation and an AI scribe that drafts the write-up for you to review, edit and approve before anything is filed. Clinical content stays under clinician control. See the full feature set and current pricing.

Frequently asked questions

How long should a psychology intake assessment take? Most practitioners use a standard session. MBS item 80110 requires a service of at least 50 minutes duration for focussed psychological strategies delivered individually in consulting rooms. Complex presentations often need a second session to finish history and formulation.

Can I bill a Medicare item for the intake session? Yes, provided the eligibility and referral requirements are met. Intake is delivered as one of the client's Better Access services and counts towards the 10 individual services per calendar year.

Do I need a new intake assessment if a former client returns? Not a full one, but you need a fresh referral for a new course of treatment and a documented update covering what has changed, current risk and revised goals. Treat it as an amendment to the record, not a replacement.

What if the client will not answer parts of the intake? Record the refusal and your clinical judgement about proceeding. Clients are not obliged to disclose everything, and APP 5.2 contemplates telling them the consequences if information is not collected, which is a conversation worth having at the time rather than later.

This article is general information for Australian practitioners, not legal, clinical or billing advice. MBS items, fees and Better Access requirements change. Confirm current requirements with MBS Online and Services Australia, and check your own professional and privacy obligations before relying on the above.

How to Write a Psychology Intake Assessment (Australia)