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Therapy Client Intake Form
Intake for therapists and counselors with goals, history and session preferences
intake · 14 fieldsFull Name*
Enter full name...
Email*
Enter email...
Phone*
Enter phone...
Pronouns
Enter pronouns...
Date of Birth*
mm/dd/yyyy
Emergency Contact (Name & Phone)*
Enter emergency contact (name & phone)...
What brings you to therapy?*
Type your answer...
What would you like support with?
Anxiety
Low mood
Stress
Relationships
Grief
Trauma
Sleep
Other
Have you been in therapy before?*
Yes
No
Current Medications
Type your answer...
Preferred Session Format*
In person
Online
Either
When are you usually available?
Type your answer...
Policies*
I have read and agree to the confidentiality and cancellation policies
Signature*
Sign here