The first session is a powerful opportunity to set the tone for a meaningful therapeutic relationship. Therapists have the unique ability to begin building a strong rapport while also meeting the essential clinical needs of an intake. This article offers a clear overview of what’s required during a telehealth intake- and shares practical tips to help you partner with your client from the very first conversation. With the right approach, the intake can be both clinically effective and a positive, connected experience for your client.
1. Welcome and Orientation to Telehealth
Welcome the client, determine their identity, and introduce yourself to establish rapport. Explain your role and Rula’s role in their care, and outline what to expect in this first session. Please note that the identified patient is required to attend the first session; the session cannot be billed if they do not attend.
"Hi [Client's Name], it’s so nice to meet you! I’m [Your Full Name], and I’m a licensed [Your Professional Title].
“I partner with Rula to help me focus on the part of being a therapist that is most important: helping you meet your goals. Rula handles all of the billing/insurance and logistical concerns on my behalf, and has a Support team available to you if you ever need help or to get a hold of me. They can also assist with any technical issues you may have. They will also send occasional surveys to you about your progress in treatment and experience in therapy, which will be helpful in continuing to tailor your therapy as your needs change.”
“Since we’re meeting virtually, I want to make sure you’re aware of the benefits and some of the challenges of receiving care in this setting to ensure this feels like a good fit for you. Do you have any questions about virtual therapy?”
Then, outline what to expect in this first session:
“The goal of today’s session is for me to gather some information about your background and for us to establish some tentative goals for your therapy. Please note that this first session might feel different than other sessions because I’ll be asking a lot about you, but this information is really important so we can figure out how I can help you best.”
Unique considerations:
- For minors between the age of 5-12, we require the consenting parent/guardian to be present at the first appointment (Initial Assessment) to confirm medical decision making authority. If a parent/guardian is not able to attend, the session should be rescheduled For ages 13-17, parental/guardian attendance is not required, but is recommended.
- For couples/family therapy, only the identified patient is considered to be a patient in the primary patient billing model that allows Rula to bill insurance for couples/family work. All parties other than the identified patient need to be aware of this, should sign the third party agreement for services, and be included as part of the patient's chart.
2. Establishing Confidentiality, Safety Protocols, and Limits of Confidentiality
Ensure the client feels safe sharing in a virtual space by reviewing the main points of informed consent. This can include discussing confidentiality and clearly explaining the limits of confidentiality, as well as discussing your status as a mandated reporter and the risks and benefits of therapy. Establish a protocol for emergencies or technology issues, and also be sure to set expectations that you are required to confirm the client’s location and document their address at the start of every session.
Confidentiality is a cornerstone of therapy, and discussing its boundaries can help clients feel safe. However, it’s equally important to communicate the legal and ethical limits to confidentiality, such as situations involving harm to self or others, abuse, or court orders. Clarifying these limits early on sets appropriate expectations and builds trust.
Here are some examples of ways to bring up these topics with your clients:
- “I ask that you find a confidential space for every session where no one else is present and where no one can overhear our conversation.
- I ask that you find a safe space to meet where you can solely focus on therapy. Please refrain from driving during your sessions.
- I am required to document your location at the start of every session. Would you be willing to share this information with me on an ongoing basis at the start of every session?
- I also wanted to let you know that I am a mandated reporter, which means I am required by law to report any potential abuse or neglect of a vulnerable party, which can include a child, an elder, or a person with an identified disability, along with any imminent life-threatening harm to yourself.
-
In order to serve you effectively and to ensure I am meeting insurance requirements, we do need to be able to use both audio/video for all of our sessions. Phone-only sessions would only be available in case of emergency or if we can’t get our technology to work.”
"That being said, there are a few situations where I am legally and ethically required to break confidentiality. For example, if I believe there’s a risk of harm to you or someone else, if there’s any indication of abuse involving a minor, elder, or dependent adult, I may need to share information with the appropriate parties. I’ll always try to discuss this with you first whenever possible."
“Since we’re meeting virtually, it’s also important to have a backup plan in case of a technology issue or emergency. Could you provide a phone number where I can reach you, as well as an emergency contact? This is just to ensure we have a safe way to connect if needed. “
Finally, confirming and documenting a client’s location at the start of each session is essential for ensuring their safety and meeting legal and ethical telehealth requirements. It allows you to respond appropriately in case of an emergency and ensures you’re practicing within your licensed jurisdiction.
“Before we dive in, I just need to confirm the address where you're located today. It’s a standard part of telehealth, so we can make sure everything is documented correctly and in line with licensing requirements.”
3. Completing an Intake Assessment
An intake assessment gathers information about the client's mental health history, family background, physical health, and current life circumstances. This can also be a prime opportunity to introduce the idea of goals in therapy, which can translate to treatment plan creation later in the session.
Rula encourages you to prioritize essential areas while remaining attuned to the client’s comfort level. If you are unable to complete particular sections of the intake, we encourage you to document that you were unable to address this in the section and your plan to do so in a future session. With that said, please keep in mind that 90791 can only be billed once during a client’s treatment episode; if an intake is unable to be completed in one session, it is recommended to bill 90791 in the first session only.
Finally, a risk assessment and treatment plan are REQUIRED at the end of the first session; you will not be able to sign and submit a note without it, so we encourage you to prioritize these important components of the intake.
"To better understand how I can support you, I’d like to gather some background information about you. I’ll ask a few questions about your mental health history, family background, and what you’re currently experiencing. This will help me form a clearer picture of your needs. Some of these questions may feel a bit formal, but they’re part of the assessment process. There are also some questions about some more sensitive topics like suicide, self-harm, and substance use, but these are important to ensure that I know how we can keep you safe. Please let me know if you need a break, don’t feel like you would like to answer a question, or if anything feels overwhelming as we go along."
“To start, I’d love to hear more about what brings you to therapy right now, at this point in your life. Do you have any sense of any goals or what you would like to accomplish in therapy?”
“You may notice that I’m typing as you talk. I will be recording what you share with me to ensure I capture your words effectively.”
4. Discussing Diagnosis
Introduce the concept of diagnosis in a non-pathologizing, compassionate way by explaining its purpose, both as a tool for understanding their experience, finding community, and being able to identify modalities that may best address their needs, but also for billing reasons. A diagnosis is necessary for insurance to cover sessions; if a diagnosis is not identified, then the client will likely be transitioned to self-pay.
For couples/family: please consider sharing with the couple/family that the primary patient needs a diagnosis in order for services to be covered by insurance.
"Part of my role is to help identify patterns in what you’re experiencing. Sometimes, we use diagnostic terms that help us understand these patterns and communicate with insurance for billing purposes. You may have heard of codes called ‘F-codes,’ which are diagnostic codes that allow us to work with insurance and get coverage for your sessions."
"A diagnosis doesn’t define you; it’s just a way to capture certain experiences so we can address them more effectively. If at any point you’re curious or have questions about this, please let me know, and I’m happy to explain more."*
5. Setting Initial Goals and Expectations
Collaborate with the client to set preliminary goals and outline a potential therapeutic approach. Where possible, attempt to capture quotes about what the patient would like to accomplish in therapy so this can be captured in the treatment plan. Use this information to create measurable treatment goals.
"I’d like to discuss your goals for therapy. Some clients have specific things they want to work on, like reducing anxiety, while others might be looking for a safe place to process their thoughts."
The first session is also a powerful opportunity to set expectations, build trust, and introduce your client to Measurement-Informed Care (MIC). By explaining how brief surveys will help track their progress and guide your work together, you position therapy as a collaborative process from day one. MIC empowers clients to reflect on their growth and helps you tailor treatment more effectively, leading to better outcomes and stronger engagement.
"As part of our work together, Rula will send you some check-ins on my behalf that ask you to complete some questions about how you’re feeling. These scientifically-backed surveys helps us track your progress and make sure therapy is working for you. I’ll be able to see your responses, and this will help us guide our sessions and give us both a clearer picture of what’s helping and where we might need to adjust. Let me know if you ever have questions about the surveys or your results- I’m always happy to talk them through."
6. Addressing Next Steps
Clarify session details, including duration, frequency, how to contact you, and scheduling options. Thank them for their difficult but courageous work in completing an intake with you.
By balancing structure, flexibility, and time management, you can provide a comprehensive, patient-centered first session that sets the stage for a successful therapeutic relationship.
Updated