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Counseling Referral Form

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Counseling Referral Form

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Psychotherapy Intake Form

We kindly ask your cooperation in answering the questions below as accurately as possible since they will assist your counselor in assessing your needs pre-appointment.

Section 1: Demographics & contact information

Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Cell Phone Number
(000) 000-0000
Please enter a valid phone number.
Home Phone Number
(000) 000-0000
Please enter a valid phone number.
Email
example@example.com
Gender
Please Select▾
Age
ex: 23
Birth Date
MM-DD-YYYY▦
Date
Preferred contact method
PhoneEmailText

Section 2: Emergency contacts & safety

Emergency contact name
Relationship
Emergency contact phone
(000) 000-0000
Please enter a valid phone number.
Would you like to share more about your current wellbeing and safety?
NoYes
If yes, please share what you would like us to know
Are you currently experiencing a crisis or thoughts of harm?
NoYes

Section 3: Safety assessment

In the past two weeks, have you had thoughts of self-harm?
NoA littleOften
Have you ever attempted suicide?
NoYes
Are you currently having thoughts of harming yourself or others?
NoYes
Recent thoughts of suicide or self-harm — please describe

Section 4: Medical & mental health history

Current medical conditions
Past mental health diagnoses
Current medications
Allergies

Section 5: Trauma history

Have you experienced any of the following? (check all that apply)
Physical abuseEmotional abuseSexual abuseNeglectDomestic violenceCommunity violenceSerious accident or injurySudden loss of a loved oneNone of the abovePrefer not to say
Approximate age(s) when this occurred
Have you ever received support or therapy related to these experiences?
YesNo
How do these experiences affect you today?

Section 6: Family & social history

Family mental health history
Relationship / marital status
Living situation
Social support
Were you adopted?
YesNo
Where did you grow up?
List your siblings and their ages
Did your parents divorce?
YesNo

Section 7: Current concerns

What brings you in today?
How long has this been present?

Section 8: Goals for therapy

What are your goals for therapy?
What would a successful outcome look like for you?
Which goal feels most important to start with?

Section 9: Substance use history

Substance use history
Frequency of use
Do you exercise regularly?
YesNo
How much time each day do you exercise?
Have you ever tried any of the following? (check all that apply)
MethamphetamineCocaineStimulants (pills)HeroinLSD or hallucinogensMarijuanaPain killers (not as prescribed)MethadoneTranquilizers / sleeping pillsAlcoholEcstasyOther
Have you ever smoked cigarettes?
YesNo
If yes, how many packs per day?
For how many years?
Other behavioral health information

Section 10: Treatment history & medications

Previous treatment or therapy
Current providers
Current medications
Notes

Section 11: Past psychiatric medications

If you have ever taken any of the following medications, please indicate the dates and daily dosage.

Psychiatric medications you have ever taken
Have you ever taken it?DatesDosageSide Effects?
Prozac (fluoxetine)
Zoloft (sertraline)
Luvox (fluvoxamine)
Paxil (paroxetine)
Celexa (citalopram)
Lexapro (escitalopram)
Effexor (venlafaxine)
Cymbalta (duloxetine)
Wellbutrin (bupropion)
Remeron (mirtazapine)
Serzone (nefazodone)
Anafranil (clomipramine)
Pamelor (nortriptyline)
Tofranil (imipramine)
Elavil (amitriptyline)
Tegretol (carbamazepine)
Lithium
Depakote (valproate)
Lamictal (lamotrigine)
Topamax (topiramate)
Seroquel (quetiapine)
Zyprexa (olanzapine)
Geodon (ziprasidone)
Abilify (aripiprazole)
Clozaril (clozapine)
Haldol (haloperidol)
Prolixin (fluphenazine)
Risperdal (risperidone)
Ambien (zolpidem)
Sonata (zaleplon)
Rozerem (ramelteon)
Restoril (temazepam)
Desyrel (trazodone)
Adderall (amphetamine)
Concerta (methylphenidate)
Ritalin (methylphenidate)
Strattera (atomoxetine)
Xanax (alprazolam)
Ativan (lorazepam)
Klonopin (clonazepam)
Valium (diazepam)
Tranxene (clorazepate)
Buspar (buspirone)
Other medications?

Section 12: Primary care physician

Primary care physician name
Clinic or practice name
Phone Number
(000) 000-0000
Please enter a valid phone number.
May we contact your primary care physician about your care?
YesNo

Section 13: Relationship

What is your relationship status?
MarriedSeparatedWidowedOtherNever MarriedDomestic Partnership
How would you rate your relationship well-being?
12345678910
Not functioningNo problems

Section 14: Employment

What is your employment status?
EmployedRetiredDisabledHomemakerOtherUnemployedSelf-employedStudent
Your average monthly income (USD)
ex: 23
USD

Section 15: Family & household

Including yourself, how many people live in your household?
−1+
Total household monthly income (USD)
ex: 23
USD
Family history of any of the following conditions (check all that apply)
YesNoIndicate Family Member
Anxiety
Depression
Substance abuse / alcohol
Arrests
Obesity
Schizophrenia
Suicide attempt
Domestic violence
Additional comments
How would you rate your family relationship?
12345678910
Not functioningNo problems

Section 16: History

Have you previously received any type of mental health services?
YesNo
If yes, please describe the services you received
Are you currently on psychiatric medication?
YesNo

Section 17: General health information

How would you rate your physical health condition?
12345678910
Very PoorExcellent
How often do you exercise?
12345678910
NoneVery Often
How would you describe your general appetite?
12345678910
Very PoorVery Hungry
How would you describe your stress level throughout the day?
12345678910
Very RelaxedVery Stressed
How would you rate your general happiness and well-being?
12345678910
Very unhappyVery happy

Section 18: Symptoms

Please answer all of the statements below that describe your concerns

I often experience
Fear of many thingsGuiltPanic attacksAvoiding peopleHaving nightmaresAnxiety, nervousnessDiscomfort in social situationsSexual issuesOther
I often have
Suicidal thoughtsMemory problemsSleeping disorderStruggled to explain myself to othersObsessive thoughtsViolent thoughtsStress and tensionMedical concernsFatigueWork problemsOther
I often feel
LonelyEmptySadHopeless about the futureExcessive guiltSuspiciousOther

Section 19: Referral source

How did you hear about us?
Doctor or provider referralFriend or familyInsurance directoryOnline searchSocial mediaOther
Referred by (name, if applicable)
Reason for referral (if applicable)

Section 20: Appointment & availability

Please check your available times for a weekly appointment? (Check as many as applies)
MondayTuesdayWednesdayThursdayFriday
9:00 AM - 10:00 AM
10:00 AM - 11:00 AM
11:00 AM - 12:00 PM
1:00 PM - 2:00 PM
2:00 PM - 3:00 PM
3:00 PM - 4:00 PM
4:00 PM - 5:00 PM
Please book an available time for your first appointment?
06/29/2026▦
9:00 AM - 10:00 AM10:00 AM - 11:00 AM11:00 AM - 12:00 PM1:00 PM - 2:00 PM2:00 PM - 3:00 PM3:00 PM - 4:00 PM4:00 PM - 5:00 PM

Section 21: Insurance status

Do you have insurance?
YesNo

Section 22: Consent, notices & policies

I acknowledge the consent, notices, and office policies provided.
I acknowledge
Signature
Your signature
✕
Printed name
Date signed
MM-DD-YYYY▦
Guardian signature (if under age 18)
Your signature
✕
Guardian printed name
Relationship to patient (if applicable)
Submit

A counseling referral form moves a client between providers without losing the story: who is referring, why, what has been tried, and the client’s written permission for information to follow them. A structured referral saves the receiving counselor a week of phone tag.

Use the builder above to assemble yours in minutes: pick a starting template, keep the sections you need, add your own questions, and download a print-ready PDF or send it digitally for e-signature.

What a counseling referral form should capture

  • Referring party — name, role, organization, and contact details
  • Client details — name, date of birth, and best contact method
  • Reason for referral — the presenting concern and why this provider or service
  • Relevant history — prior counseling, current supports, and anything the receiving counselor should know
  • Urgency — routine, priority, or same-week, with a clear flag
  • Consent to share — the client’s signed permission for records to move with the referral
  • Receiving provider section — space for the accepting counselor to confirm and note next steps

5 signs your referral process needs a real form

  • Referrals arrive by voicemail — half the details missing, no written consent attached
  • Clients repeat their story from zero — nothing traveled with the referral
  • No one knows the urgency — every referral is treated the same, including the ones that should not wait
  • Consent is verbal — records move on a handshake instead of a signature
  • You cannot find last month’s referral — there is no single place they live

Send referrals digitally, keep a paper option

Build the referral form once: the referring party completes it online, the client signs the consent-to-share electronically, and the receiving practice gets a clean PDF — or print the same form for fax-first organizations. Either way every referral is complete, signed, and filed the same way.

Frequently asked questions

›What is a counseling referral form?

A structured document used when one provider refers a client to a counselor: it captures the referral reason, relevant history, urgency, and the client’s signed consent for information to be shared with the receiving provider.

›Who fills out a counseling referral form?

Usually the referring provider (a physician, school counselor, EAP, or another therapist) completes the referral details, and the client signs the consent-to-share section.

›Can the client sign the referral electronically?

Yes. The consent-to-share section supports e-signature on any device, with the signing date filled automatically.

›Can I customize the referral fields?

Fully - add your own fields (for example, program eligibility or funding source), remove what you do not need, and add your organization’s name and logo.

›Can referrals be sent digitally to another practice?

Yes. Send the form link to the referring party; the completed, signed referral arrives as a PDF you can forward or file.

›Is there a printable version for fax-based workflows?

Yes. The same referral form downloads as a print-ready PDF in A4 or US Letter.

›What does it cost?

Building is free; a print-ready PDF or a one-time digital send is $14.99. Plans from $19 per month cover ongoing referral volume with every response in one dashboard.