What to include in a client intake form (with examples and templates)

Client information

Full Name:

Date of Birth:

Age:

Pronouns:

Gender Identity:

Address:

City:

State:

Zip:

Email:

Phone:

OK to leave voicemail?:

OK to text?:

Preferred method of contact:

Emergency Contact Name:

Relationship:

Phone:

Technology for telehealth

Check off the device(s) you will use for sessions:

• Smartphone
• Tablet
• Laptop
• Desktop computer

Internet access is:

• Stable and private
• Somewhat reliable
• Unreliable

Preferred Telehealth platform:

• Zoom (HIPAA-compliant)
• Doxy.me
• Google Meet (HIPAA)
• Other: 

Do you have a private space for sessions?:

Telehealth consent

• I understand that telehealth services involve the use of electronic communication to enable mental health services at a distance.
• I understand the limitations of telehealth, including potential risks related to technology (e.g., interruptions, unauthorized access, or miscommunication).
• I agree to be physically located in the state of ____________ at the time of each session unless otherwise approved by the clinician. (Note: State laws often require the provider and client to be in the same state.)
• I understand that if I am experiencing a crisis (e.g., suicidal ideation, risk of harm to self or others), I may be referred to local emergency services or in-person treatment.
• I understand that I may withdraw consent to telehealth at any time without affecting my right to future care or treatment.

Presenting concerns

Briefly describe your primary concerns for seeking therapy:

When did these concerns begin?

What are your goals for therapy?

Mental health history

Have you ever seen a therapist or counselor before?:

If yes, when and for what reason?:

Have you ever been hospitalized for mental health concerns?:

If yes, please explain:

Current mental health symptoms (check all that apply):

• Anxiety
• Depression
• Trauma/Abuse
• Panic Attacks
• Mood Swings
• Sleep Issues
• Suicidal Thoughts
• Self-Harm
• Substance Use
• Relationship Issues
• Stress
• Other:

Have you ever engaged in self harm?:

If yes, when?:

Have you ever attempted suicide?:

If yes, when?:

Have you experienced any major life changes or losses recently?:

If yes, please describe:

Medical & psychiatric history

Current medical conditions:

Current medications (list name, dosage, and reason):

Primary care physician or psychiatrist (name/contact):

Any recent hospitalizations (past 12 months)?:

Substance use

Do you currently use any of the following?

• Alcohol – How often?
• Tobacco – How often? __________
• Cannabis – How often? __________
• Other substances (prescription or illicit): ____________
• 
  

Have you ever had concerns about your substance use?:

Social history

Relationship status:

• Single
• Married
• Divorced
• Partnered
• Widowed
• Other: 

Children (names & ages): 

Who lives in your household?:

Support system (friends, family, community):

Religious or spiritual affiliation (if any):

Cultural or identity factors important to your care (race, ethnicity, gender identity, immigration, etc.):

Employment & education

Occupation:

Employer:

Currently working?:

Highest level of education completed:

• High school
• Some college
• College degree
• Graduate degree
• Other: 

Insurance & billing information (if applicable)

Insurance Provider:

Policyholder Name:

Relationship to Client:

Member ID:

Group #:

Billing Address: 

Consent & signature

• I understand that the information provided in this form is confidential and will be used for treatment planning and care coordination. I understand that my therapist may discuss relevant information for clinical supervision or as required by law (e.g., danger to self/others, mandated reporting).
• I understand and consent to participate in telehealth therapy services. I agree that the information I have provided is accurate and complete to the best of my knowledge.

Client Signature:

Date:

Clinician Signature (upon review):

Date: