Initial Assessment

Every client (individual, couple, or family) receiving treatment at Rula must have an Initial Assessment (CPT 90791) completed during the first visit. The Initial Assessment serves as the foundation for identifying treatment needs, establishing a diagnosis, and determining therapeutic fit. This article reviews the clinical information you'll collect in the Initial Assessment Template and includes a FAQ section.

Initial Assessment Details

Before beginning this session, it is advisable to orient the client to the clinical purpose of the initial assessment. This sets expectations for the session and the information to be obtained and supports the client in understanding the “why” of the assessment before actual therapy can begin. 

• “I am so glad you are here. Our goal for today is to ensure I have a good understanding of what is bringing you to therapy and how I can support you in meeting your treatment goals before we start the therapy process. I’m going to ask you a variety of questions that will help us do this.”  

Then you'll collaboratively work your way through the Initial Assessment template, which collects valuable clinical information on the following:

• Presenting problem - What brings the client to seek mental health treatment? You'll want to identify why the client is seeking treatment at this time, including the onset, duration, and severity of symptoms. To support medical necessity for services, it is important that this section includes specific clinical information related to the client’s mental health symptoms as well as how these mental health symptoms are impairing the client's functioning, such as increased isolation, loss of relationships, and decreased performance at work. 
  
  

  Example: Instead of writing “Client has anxiety,” be more specific as to which DSM-5-TR criteria they experience to justify a diagnosis of anxiety, such as chronic worry, intrusive thoughts, and/or difficulty focusing to support medical necessity.

• Health history (Medical conditions, current medications) 
  
  
• Psychosocial (Interpersonal/family relationships, Education, Employment, Living situation, Trauma or abuse history)
  
  
• Cultural considerations - A culturally responsive approach to care includes recognizing how culture can affect help seeking behavior, manifestation of symptoms and selection of effective interventions. “Culture” can include a variety of considerations such as ethnicity/race, age, sexual orientation, gender identity, values/beliefs, language, socioeconomic status, family dynamics, and/ or religious/spiritual identities. Answers such as “N/A or None” in this field are flagged.
  
  
• Substance use history
  
  
• Mental health treatment history
  
  
• Population-specific questions (i.e questions specific to couples, families or child/adolescent clients) 
  
  
• Risk assessment - This section needs to be completed regardless of whether or not the client has a presenting problem related to risk.
  
  
• Mental Status Exam (MSE) 
  
  
• Clinical summary - This summarizes the presenting problem, symptoms, diagnosis, functional impairments, and justification for services. It is not a repeat or copy/paste of the presenting problem and should clearly identify the need for treatment and the justification of a diagnosis.
  
  
• Diagnosis
  
  
• Initial treatment plan 

Initial Assessments also offer a space for clients to ask any questions that they may have about the therapeutic process, cancelation policies, billing and payment, scheduling availability, etc. 

Initial Assessment FAQs

• How long should an Initial Assessment take? Initial assessments typically last 60 minutes but can vary especially if conversations with family members are involved. Initial assessments (CPT code 90791) require a minimum of 16 minutes and a maximum of 90 minutes in order to receive reimbursement. You may not schedule (or bill for) any additional initial assessments with the same client in order to finish the initial assessment due to time constraints.
  
  
• If I bring an established client with me, do I have to complete another initial assessment through Rula? Yes, you will need to complete another initial assessment even if one already exists. The new assessment will establish a new episode of care here at Rula. If this is not documented, it may be unclear when the transition occurred.
  
  
• If the client is a minor, can I complete an Initial Assessment with only the parent/guardian present (no client) since they have most of the historical information anyway? For minors under 13, the consenting parent/guardian is required to be present at the first appointment, and it is recommended that a parent be present for the first visit with adolescents ages 13-17. While family members should be involved, the minor, as the primary client, must also be present for at least a portion of the session. This is because some required elements of the Initial Assessment, such as the MSE, require you to assess the actual client, not a family member.
  
  
• Do I have to fill out every field in the Initial Assessment note template? Any field that is yellow must be completed, as it has been mandated by our insurance payers and is necessary for reimbursement. You will not be able to sign the Initial Assessment without completing these fields.
  
  
• How does the Initial Assessment for Couples or Families differ from the initial assessment for individuals? There is a different assessment template for couples and families, which features additional tabs and sections to support care for those clients. Any time a couple or a family is in treatment, one individual is identified as the Primary Patient. You'll document care in this individual’s medical chart, and the diagnosis and billing information will be submitted for the primary patient. Rula only requires a diagnosis for the Primary Patient. 
  
  
• What if I am not able to determine an official diagnosis during the Initial Assessment, but I do think the client needs treatment? It’s not uncommon to need some additional time to determine a diagnosis. However, the note and charge slip cannot be signed if you don't identify a covered diagnosis. In these cases, consider the use of an interim “unspecified” diagnosis until you can confirm something more precise. You may also use “F99 - Mental disorder, not otherwise specified” for 1-2 sessions while you further evaluate a client's symptoms. 
  
  
• What if the client and I don’t have enough time to create a Treatment Plan during the Initial Assessment? A treatment plan is a required component of the Initial Assessment in order to be able to sign and bill for the appointment. While the aim should always be to set some preliminary treatment goals and objectives during this first encounter, if you run out of time you may enter a preliminary goal such as “Establish therapeutic rapport,” or “increase understanding of mental health needs,”  The first therapy session should then have a primary focus of clarifying the treatment plan so the therapist and client are in agreement of client goals, objectives, and treatment approaches for care before moving forward. 
  
  

• A client was rematched to me after working with a different therapist at Rula, do I need to complete a new Initial assessment? Yes, it is best practice to complete a new assessment at the onset of care with any new client, even if they recently completed one with a different therapist. The assessment of symptoms, diagnosis, and treatment needs should always be based on your own evaluation and assessment skills and not the previous evaluation of another therapist, whose assessment and conceptualization of care needs may differ from yours. This ensures the best possible care and avoids potential issues with higher level of care (HLOC) referrals or risk management.
  
  

• Can I see examples of completed Initial Assessments? You got it! Click HERE. 

If you have questions or support needs related to initial assessments,  reach out to our clinical quality team at quality@rula.com. Therapist to therapist - we’re here for you!