The intake interview: what to ask in the first session

The first session does double duty. Clinically, it is where the alliance and your understanding of the case begin; administratively, it is where the record opens: the intake history, the consents, the baseline scores, the first note. This guide is about the second job. It is not a clinical protocol and does not replace your training in interviewing: it is a map of the areas to cover in session one and how to leave them documented — what the academic sources agree belongs in an intake, which paperwork attaches to it, and the one screen no first session should skip.

Why the intake deserves structure

The APA Ethics Code (Standard 6.01) lists the first purpose of clinical records plainly: to facilitate provision of services later, by you or by another professional. The APA’s Record Keeping Guidelines add the practical stakes: appropriate records help protect both the client and the psychologist if anything reaches a legal or ethical proceeding, and adequate records are generally a requirement for third-party reimbursement. Nowhere does the record earn that value more than at intake, because everything that follows — the treatment plan, the progress comparisons, the eventual closing summary — is built on what you capture in session one.

Many jurisdictions also regulate what a clinical record must contain. In Mexico, for example, the clinical-record norm (NOM-004-SSA3-2012) lists minimum interview contents — identification data, family history, personal history including tobacco, alcohol and other substance use, and the presenting problem including prior treatments — and contains an adjustment clause under which psychological records in independent outpatient practice are adapted to the nature of the services provided. Two lessons travel well beyond Mexico: check what your jurisdiction actually requires, and be skeptical of any site promising an “official” universal intake template — in most places, no such thing exists.

Digging deep into someone’s life before setting the frame is doing the session backwards. The APA Ethics Code requires informing clients “as early as is feasible” about the nature and anticipated course of therapy, fees, involvement of third parties, and limits of confidentiality, with sufficient opportunity to ask questions (Standard 10.01); and Standard 4.02 places the conversation about confidentiality limits at the outset of the relationship — that is, before the deep disclosure starts, not after.

There is usually a second, legal layer: in many countries, health information is a specially protected category of personal data, and processing it takes explicit consent. In Mexico, for example, the data-protection law in force requires express written consent for health data, on paper or by electronic signature. And if you plan to record audio or use an AI tool that processes the session, that is never a default: it takes express, documented, revocable consent, agreed before anything is captured. The informed consent guide covers both layers and the special cases, minors included — and wherever you practice, verify the rules that apply to you.

The areas to cover, with example questions

The lists of “first-session questions” that circulate online have no official origin: they are professional convention. What does exist is academic literature on the content of the initial interview. The StatPearls review of interview techniques describes an open-ended opening — inviting the person to share their concern while you show active listening — and content that includes chronology, onset, description, intensity, exacerbating and remitting factors, associated symptoms, social history, medical history, hospitalizations, family history, and current medications. The frame that organizes all of it is the biopsychosocial model: attending simultaneously to the biological, psychological, and social dimensions, treating the client’s subjective experience as essential to understanding the case. That yields the areas below. The questions in blockquotes are fictional examples to adapt to your own style, not a script.

Presenting problem and its history

Open broad and let the person talk; structure comes second.

“What brings you in? When did you start noticing it, and what was going on in your life at the time?”

Then comes the order: chronology and onset, intensity, what makes it worse and what eases it, and how it affects work, relationships, and sleep. One detail the online lists tend to omit: ask about previous treatment of every kind — conventional and otherwise. Knowing what the person has already tried, and what helped or disappointed them, changes the plan from day one.

Histories: medical, psychiatric, substances, medications

Family history (mental health in the family included), personal medical history and current medications, hospitalizations, prior psychological or psychiatric care, and substance use — tobacco and alcohol included, which intake templates skip more often than clients expect.

“Have you been in therapy or seen a psychiatrist before? What helped and what did not? Are you currently taking any medication, including anything for sleep or anxiety?”

The social dimension of the biopsychosocial frame: who the person lives with, their support network, work or school, and what their weeks actually look like.

“Who do you live with? Walk me through a typical week — work, home, rest. Who can you count on when things get hard?”

The mental status exam

Where a physician documents a physical exam, you document your own discipline’s exam. The mental status examination’s domains, per the StatPearls review: appearance, behavior, motor activity, speech, mood, affect, thought process, thought content, perceptual disturbances, cognition, insight, and judgment. Most of it requires no extra questions — you observe it during the conversation and record it at the end. And it has a longitudinal payoff: it can be repeated across encounters to monitor how the picture evolves.

The baseline: PHQ-9 and GAD-7

A rich interview gives you the story; an instrument gives you the number everything that follows gets compared against. The PHQ-9 and GAD-7 are the natural intake choice because they are free: the official site phqscreeners.com states that the instruments and their translations — official Spanish versions included — can be downloaded and reproduced with no permission required. The PHQ-9 scores 0 to 27, with cutpoints at 5, 10, 15, and 20; in the original validation study (US primary care), a score of 10 or greater showed 88% sensitivity and 88% specificity for major depression. The GAD-7 runs 0 to 21, with cutpoints at 5, 10, and 15, and ≥ 10 as the recommended cutpoint for further evaluation per the official instruction manual.

The detail that turns these scores into a baseline is that the manual confirms the PHQ-9’s sensitivity to change: today’s number exists to be compared with next month’s. Two standing rules: no score is a diagnosis — these are screening and monitoring tools your clinical judgment integrates — and the full administration and interpretation details are in the PHQ-9 and GAD-7 guides.

Risk screening: the one thing session one must not skip

Asking about suicidal ideation in a first session makes plenty of clinicians uneasy, out of fear of “planting the idea.” The StatPearls synthesis on suicide risk assessment is direct: the evidence does not support that concern, and thoughtful inquiry is a necessary component of risk assessment. If you administered the PHQ-9, item 9 has already opened the door — and left you an obligation: the official manual states that a positive answer requires follow-up, and that the final decision about actual self-harm risk requires a clinical interview. The score is never the assessment.

As a structured complement there is the C-SSRS (Columbia scale): simple, plain-language questions about suicidal ideation, preparatory behavior, and attempts, available in more than one hundred country-specific language versions. Complement is the exact word: the same academic source stresses that these instruments support screening but do not substitute for a formal, structured clinical evaluation that integrates the interview, collateral sources, and the record. Neither does this guide: any disclosure of risk calls for an immediate clinical assessment under your own protocol and training, documented in the note — what you found and what your decision rests on. And keep the crisis resource documented in the chart and shared with the client: the contact information for the crisis line serving your client’s location, alongside local emergency services.

From interview to record

The intake history you just took is a record entry and follows record rules. Date, author, and signature on every entry is good practice everywhere and a formal requirement in some jurisdictions — in Mexico, for example, every note must carry date, time, the author’s full name, and a handwritten, electronic, or digital signature. Retention also varies: as US guidance, the APA Record Keeping Guidelines suggest — explicitly “in the absence of a superseding requirement” — considering keeping full records until 7 years after the last date of service for adults, or until 3 years after a minor reaches majority, whichever is later; Mexico’s norm, by contrast, sets a minimum of 5 years from the last act of care. Verify the rule where you practice and treat it as a floor.

Above all, documenting session one well is an investment: the intake feeds the treatment plan with SMART goals that follows it, and it fixes the baseline against which your session notes will show real change.

The stumbles that repeat most in practice:

Exploring before framing. Confidentiality limits are explained before the deep disclosure, not after; the written consent is not left “for next time.”
Recording the score without the assessment. A positive item 9 filed away with no note of the follow-up evaluation is the hardest gap in a record to explain later.
The “to be completed” intake. A first note without date, author, or signature fails the basics from the start; if an area went unexplored, write that it is pending and when you will return to it.
Turning the interview into an interrogation. The areas are a map, not a questionnaire to read in order; the opening is open-ended and the listening active. The alliance is also built in session one.
Closing without a next step. The first session ends with an honest initial impression, a preliminary plan, and a next date — and that is what gets documented.

A good intake interview produces a lot of material in a single hour: history, consents, scores, a first note. gesell.ai is built so none of it scatters: it keeps a structured chart for every client — intake, clinical history, treatment plan, and session notes — includes built-in validated scales with automatic scoring such as the PHQ-9 and GAD-7, and turns your session record into a draft note that you review, adjust, and approve. You conduct the interview; keeping the chart in order no longer depends on your memory.