Clinical Thinking Tools · Document 1 of 3
Intake Guide
What to understand, what OHP requires, and how the pieces connect
Goals
What does the client want?
Gaps
What's in the way right now?
Roots
What shaped this pattern?
Restraints
What keeps it stuck?
Resources
What's already working?
Each category informs the others — gaps clarify roots, roots explain restraints, resources reframe all of it. This is a feedback loop, not a checklist.
Goals
What brings this person in, and what do they want to be different?
OHP Required
Try to understand
- Presenting problem in the client's own language — what they say, not a clinical translation
- Why now — what shifted or escalated that made this the moment to seek help
- What success would look or feel like from their perspective
- What they've already tried, and what has or hasn't helped
- How motivated and ready do they seem — and what might be shaping that
OHP documentation requires
- Presenting problem and reason for referral
- Client-stated goals for treatment
- Reason for service and clinical necessity
Gaps
How is the problem showing up in this person's life right now?
OHP Required
Try to understand
- Functioning across domains — work or school, relationships, daily self-care, health
- Where impairment is most significant: safety, basic needs, or relationships
- Symptom picture — frequency, duration, severity, and what triggers or worsens it
- What has changed recently that activated or escalated the current presentation
- Current stressors, including structural and environmental factors
OHP documentation requires
- Mental status exam
- Symptom description with frequency, duration, severity
- Functional impairment in major life areas
- Risk assessment — safety, self-harm, suicidality
- Substance use history and current use
Roots
What history explains why this pattern developed in this person?
OHP Required
Try to understand
- Developmental and relational history — family of origin, significant relationships
- Trauma history: what happened, when, and what support was available
- Cultural background, identity, community context, and how these shape the presenting picture
- Structural and systemic factors — poverty, racism, housing instability, immigration, systems involvement
- Prior treatment: what, when, what helped, what didn't, and what the client makes of it
- Medical and psychiatric history relevant to current presentation
OHP documentation requires
- Psychiatric and mental health history
- Medical history and current medications
- Trauma and adverse childhood experiences (ACEs)
- Family history of mental health and substance use
- Social and developmental history
- Cultural and linguistic considerations
- Previous treatment and response
Restraints
What is keeping this pattern in place right now?
Try to understand
- Patterns the client notices repeating — in relationships, behaviors, responses
- Coping strategies that once worked but now create their own problems
- Avoidance — what the client moves away from and how
- Current relational dynamics that reinforce the presenting picture
- Structural barriers: access, housing, finances, caregiving demands, discrimination
- Beliefs about self, others, or the world that maintain the pattern
Why this matters for documentation
- Maintaining factors are what justify continued treatment
- Barriers to treatment must be documented if they affect engagement
- This section grounds the formulation — what you name here becomes the target
Restraints aren't always internal. Notice how much is individual, relational, and structural — that balance shapes what treatment can realistically address.
Resources
What strengths, capacities, and supports are already present?
OHP Required
Try to understand
- Strengths the client names about themselves — and those you observe in the room
- Relationships that provide support, safety, or stability
- Community, cultural, or spiritual resources the client draws on
- How this person has survived and adapted — even when those strategies have costs
- Prior experiences of change or growth that could inform treatment
- Capacity for insight, reflection, and engagement
OHP documentation requires
- Identified strengths and protective factors
- Social support and natural supports
- Client preferences and cultural considerations for treatment
Resources are not just a documentation box to check. They change the formulation. What you find here should loop back and inform what goals are realistic and what treatment can build from.
Diagnostic Impression
A conclusion drawn from across all five categories — not a starting point
OHP Required
OHP documentation requires
- DSM-5 diagnosis with full code
- Diagnostic rationale tied to presenting symptoms
- Rule-outs and differential considerations noted
- V/Z codes for relevant psychosocial stressors
- Level of care justification
Clinical thinking prompt
Given what you've gathered across Goals, Gaps, Roots, Restraints, and Resources — what does the diagnostic picture look like? Where does the diagnosis fit the client's own understanding, and where does it fall short of the full story?