Client Assessment & Treatment Planning

Lesson 1 of 10

Intake and Health History

An intake conversation helps the therapist understand the client’s reason for seeking care, relevant health context, and preferences. Ask clear, respectful questions and allow time for the client to explain in their own words. Information should guide safe service decisions, not invite diagnosis. Protect confidentiality and follow applicable law, workplace policy, and professional standards for record handling.

Key points

• Ask about the primary concern, onset and course, relevant health conditions, medications, allergies, and prior care as appropriate.
• Use open questions first, then clarify specifics; avoid leading language that suggests the answer you expect.
• Ask how the concern affects daily activity and what changes the client hopes to experience.
• Clarify current symptoms and relevant precautions; pause or adapt service if answers raise a safety concern.
• Use plain language, confirm understanding, and invite questions without pressuring disclosure beyond what is relevant.
• Record relevant information objectively and securely, following applicable privacy requirements and workplace procedure.

Key terms

Intake

The initial process of gathering information and orienting a client to services.

Health history

Client-reported health information relevant to planning safe care.

Open-ended question

A question that allows a client to answer in their own words.

Confidentiality

The duty to protect private client information from inappropriate access or disclosure.