Atlanta Telehealth
Fillable Intern Intake Script (Initial Assessment)
| Patient Name: ___________________________ |
DOB: __/__/______ |
| Date/Time: __/__/______ ______ AM/PM |
Clinician: ___________________________ |
| Visit Type: [ ] Telehealth [ ] Phone [ ] In-person |
| Referral Source: [ ] VA [ ] Self [ ] Other: ___________________________ |
1) Opening + Orientation
Script: “Hi ____________. I’m ____________ with Atlanta Telehealth. Today I’ll ask some questions to understand what brings you in, what symptoms you’re having, and what goals you want to work on. Some questions are about safety and history. You can pause or skip anything you’re not ready to discuss.”
Patient agrees to proceed? [ ] Yes [ ] No
Any immediate concerns today? [ ] Yes [ ] No
If yes, describe: _________________________________________________
2) Presenting Concern
1. “What brought you in today?”
Response: _______________________________________________________
2. “When did these concerns start or become significantly worse?”
Timeline/Onset: _________________________________________________
3. “What do you think triggered it (work stress, trauma, transitions)?”
Triggers: _______________________________________________________
4. “What feels hardest right now (sleep, anxiety, mood, motivation)?”
Main difficulty: _________________________________________________
3) VA / Prior Treatment Context
1. “Have you received mental health care through the VA before?” [ ] Yes [ ] No
Notes: __________________________________________________________
2. “Did anything about the transition to community care affect your mood/anxiety?”
Notes: __________________________________________________________
3. “Have you had therapy before? What helped/didn't help?”
Notes: __________________________________________________________
4. “Have you taken psychiatric medication before?” [ ] Yes [ ] No
What medication(s)/Side effects: __________________________________
4) Depression Symptoms (Last 2 weeks)
- [ ] Low mood / sadness
- [ ] Loss of interest/pleasure
- [ ] Low energy/fatigue
- [ ] Sleep changes
- [ ] Appetite/weight changes
- [ ] Concentration problems
- [ ] Worthlessness/guilt
- [ ] Hopelessness
Other: ___________________________
Impact on functioning: ____________________________________________
5) Anxiety Symptoms (Last 2 weeks)
- [ ] Excessive worry
- [ ] Racing thoughts
- [ ] Feeling “on edge”
- [ ] Muscle tension
- [ ] Irritability
- [ ] Panic symptoms
- [ ] Avoidance
- [ ] Difficulty concentrating
Top worries: ____________________________________________________
Worst times of day: [ ] Morning [ ] Afternoon [ ] Night
6) Sleep & Work / Functional Impact
1. “How many hours are you sleeping on average?” _______ hrs/night
Trouble: [ ] Falling asleep [ ] Staying asleep [ ] Waking early
What thoughts keep you up?: _______________________________________
2. “Are you currently working?” [ ] Yes [ ] No
3. “How have symptoms affected your ability to work or keep a job?”
Notes: __________________________________________________________
4. “Financial stress currently?” [ ] Yes [ ] No
7) Trauma / Military Screening (gentle)
Script: “I ask everyone a few questions about difficult experiences because they can affect anxiety, mood, and sleep. You don’t have to share details today.”
1. “Any military experiences or other events that still affect you?” [ ] Yes [ ] No [ ] Not ready
[ ] Intrusive memories [ ] Nightmares [ ] Avoidance [ ] Hypervigilance [ ] Startle response [ ] Numbing [ ] Guilt/shame
8) Relationships & Substance Use
1. “Who are your main supports right now?” __________________________
2. “How is your relationship with family?”
[ ] Close [ ] Some contact [ ] Distant/limited [ ] No contact
3. Alcohol use: [ ] None [ ] Occasional [ ] Weekly [ ] Daily
4. Cannabis use: [ ] None [ ] Occasional [ ] Weekly [ ] Daily
5. Other substances: ______________________________________________
9) Safety / Risk Assessment (Ask Directly)
1. “In the last 2 weeks, have you had thoughts of not wanting to be alive?” [ ] Yes [ ] No
2. “Any thoughts of hurting yourself?” [ ] Yes [ ] No
3. “Any plan or intent?” [ ] Yes [ ] No
4. “Any history of attempts or self-harm?” [ ] Yes [ ] No
5. “Any thoughts of hurting anyone else?” [ ] Yes [ ] No
6. “Access to weapons or means?” [ ] Yes [ ] No
If yes, describe and safety plan: __________________________________
*If risk present: notify supervisor immediately.
10) Mental Status Exam & Screenings
Appearance: [ ] WNL [ ] Disheveled [ ] Other: ____________
Behavior: [ ] Cooperative [ ] Guarded [ ] Withdrawn [ ] Agitated
Speech: [ ] WNL [ ] Rapid [ ] Slow [ ] Soft
Mood: ______________ Affect: [ ] Congruent [ ] Restricted [ ] Flat [ ] Labile
Thought process: [ ] Linear [ ] Tangential [ ] Racing
Thought content: [ ] WNL [ ] Worry [ ] Compulsions [ ] SI [ ] HI
Insight/Judgment: [ ] Intact [ ] Fair [ ] Poor
PHQ-9 score: ______/27 | GAD-7 score: ______/21
11) Patient Goals & Plan
“What would you like to work on first?”
Goal 1: _________________________________________________________
Goal 2: _________________________________________________________
Recommended care: [ ] Weekly [ ] Biweekly [ ] Higher level needed
Next appointment: _______________________________________________
Closing: “Thank you for sharing today. Based on what you’ve told me, our next steps are ______.”