A diagnostic evaluation (also referred to as an intake session) is a structured, clinical assessment conducted at the beginning of psychotherapy to gather comprehensive information about you, the client’s presenting concerns, psychological history, and current functioning. This session serves as the foundation for diagnostic formulation, treatment planning, and establishing therapeutic goals.

The evaluation typically includes:

• Presenting problem and reason for seeking treatment

• Psychiatric, psychological, and medical history, including past diagnoses and treatment outcomes

• Family, social, academic, and occupational functioning

• Trauma history, substance use, and risk assessment (e.g., suicidal ideation, self-harm, abuse)

• Mental status exam and clinical observations

• Review of current symptoms and their impact on daily functioning

• Cultural, developmental, and identity factors that may influence care

The provider uses clinical interviewing techniques and may incorporate standardized screening tools or assessment measures to support diagnostic clarity.

The purpose of the diagnostic evaluation is to:

• Determine the presence of mental health conditions based on DSM-5 criteria

• Identify key strengths and stressors

• Clarify treatment needs and client expectations

• Establish rapport and provide orientation to the therapeutic process

By the end of the session or shortly thereafter, the clinician formulates an initial diagnostic impression and, if appropriate, a treatment plan outlining clinical goals, therapeutic approach, and recommendations for frequency and duration of care.