Formfy

Counseling Informed Consent Form

Builder

Counseling Informed Consent Form

Which intake form are you building?

Start from a recommended template that fits your needs. You can customize everything later.

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

The best way to write an informed consent form is to study examples. Below are four counseling consent patterns - solo practice, group practice, minors, and telehealth - with the clauses each one carries and why. Use them as a blueprint, then build your own version with the builder above.

Example 1: solo counseling practice consent form

The baseline pattern - nine short, headed sections a client can read in five minutes:

  • About counseling — two plain paragraphs on what sessions involve and what counseling can realistically offer
  • Limits of what stays between us — the specific situations that require action, listed, not implied
  • Fees — “Sessions are $140 for 50 minutes, due at time of service”
  • Cancellations — “24 hours notice; late cancellations are charged $70”
  • Between sessions — how to reach the counselor and the expected response window
  • Emergencies — “If you are in crisis, call or text 988, or call 911”
  • Records — how records are kept and how to request a copy
  • Ending counseling — either party may end the work; a closing session is encouraged
  • Acknowledgment — “I have read and understand the above” + signature, printed name, date

Example 2: group practice consent form

Adds the clauses a multi-clinician practice needs on top of the baseline:

  • Care team clause — which clinicians may be involved and how coverage works during absences
  • Supervision clause — whether associate clinicians practice under supervision, named plainly
  • Billing entity — who charges the card, since the statement name differs from the counselor’s
  • Coordination clause — how the practice coordinates when a client sees two of its clinicians

Example 3: consent form for counseling minors

The under-18 pattern reshapes the signature block and adds three clauses:

  • Guardian authority — who holds the right to consent for the minor, stated up front
  • What parents are told — the practice’s policy on what is shared with guardians and what stays with the teen
  • Two signatures — the guardian signs consent; the minor signs an age-appropriate assent
  • Guardian contact — collected with relationship to the client, not just a name

Example 4: telehealth counseling consent form

Video work adds four practical clauses:

  • Technology basics — the platform used and what happens when the connection fails
  • Location check — the client confirms the state or region they are in at session time
  • Environment — both parties commit to a private space during sessions
  • Backup plan — the phone number used if video drops, agreed in advance

Turning an example into your consent form

  • Pick the example closest to your practice — solo, group, minors, or telehealth
  • Replace the numbers — your fees, your cancellation window, your response times
  • Keep sections short and headed — clients read headed sections; they sign past walls of text
  • Make the acknowledgments required — each policy gets its own checkbox in the builder
  • Collect it before session one — send digitally for a dated e-signature, or print the same form

Frequently asked questions

›What does a good counseling informed consent form look like?

Nine short, headed sections: about counseling, limits of what stays between you, fees, cancellations, between-session contact, emergencies, records, ending counseling, and a signed acknowledgment. Concrete numbers throughout.

›Are these consent form examples free to use?

The patterns above are free to use as blueprints. The builder on this page turns them into a finished, branded form - free to build and preview, $14.99 for the print-ready PDF or a digital send.

›How does consent differ for counseling minors?

A guardian signs consent while the minor signs an age-appropriate assent, guardian authority is stated up front, and the form spells out what is shared with parents versus what stays with the teen.

›What extra clauses does telehealth consent need?

The platform used, a location check at session time, a commitment to a private environment on both ends, and an agreed phone backup if the video connection fails.

›Can I copy an example and edit it?

Yes - start the builder, pick the consent-focused template, and replace the wording with your own policies. Every clause, checkbox, and signature line is editable.

›Should each policy have its own checkbox?

Yes. Separate acknowledgments for fees, cancellations, and emergencies read as informed agreement; one catch-all checkbox reads as fine print.

›Can the signed form be collected online?

Yes. Send it digitally: the client checks each acknowledgment, signs on any device, and you receive the dated, signed PDF before the first session.