Initial assessment in the Golden Thread: Intake documentation template

Friday, September 22 2023

You may have heard of the Golden Thread and its importance in providing quality care and meeting accreditation, compliance and reimbursement requirements. The Golden Thread “ties together” or creates a cohesive narrative of a client’s experience in an episode of care and provides clear evidence of medical necessity. The narrative is documented in therapist documentation in the client’s record. The initial assessment document (intake) is the first step in the Golden Thread of clinical documentation.

What is the intake document?

The intake document is a detailed summary about the client’s background, current level of functioning, and reason for seeking care needed for the intake to support medical necessity. 

When should I use it?

As a provider, you’ll use the intake document when you meet with a new client for the first time as part of an initial assessment or evaluation. You should also use the intake document when you’re meeting with a previous client who was discharged from care. In these instances, the intake can support medical necessity for why another episode of care is beneficial based on new stressors experienced by the client.


What's in the intake document?

In addition to client demographic information, the intake includes many categories relevant to assessing medical necessity for therapy, including:

  • Background information
  • Primary reason for seeking care
  • Mental status exam
  • Risk assessment
  • Historical information about the client’s life to date

Additional components include diagnosis and initial plan for treatment. When you’re using CPT Code 90791, you’ll need to complete and submit an intake assessment document which includes an initial diagnosis and plan for treatment.


How can I get the intake document template?

As a resource for SonderMind providers, we’ve created an intake template that you can access here

To help you fill out an intake template, we’ve also developed sample intake documents featuring fictional clients. The samples contain a mix of narrative and bulleted information for each category in the template. The information in each sample is for illustrative purposes only and does not contain real client information.


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You might also want to read

The Golden Thread: Using Medical Record Documentation Templates to Prove Medical Necessity

Road map for care in the Golden Thread: Treatment plan template

Documenting therapy sessions in the Golden Thread: Progress note template

Documenting end of care in the Golden Thread: Discharge summary template

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