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Therapy Intake Form

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Therapy Intake 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 therapy intake form is the first document a new client completes before their first session: contact details, history, current concerns, goals, and consent. A good one saves the first 20 minutes of session one and gives the therapist a clear starting picture before the client walks in.

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 therapy intake form should include

  • Client information — full name, date of birth, contact details, and preferred contact method
  • Emergency contact — name, relationship, and phone number
  • Presenting concerns — what brings the client to therapy now, in their own words
  • Mental health history — previous therapy or counseling, past diagnoses, hospitalizations
  • Medical background — current conditions, medications, allergies
  • Family and social history — household, relationships, support system, work or school
  • Substance use screening — alcohol, tobacco, and other substances, with follow-ups only when relevant
  • Wellbeing check — mood, sleep, appetite, and a brief safety screen with crisis resources
  • Goals for therapy — what a successful outcome would look like to the client
  • Consent and policies — session policies, fees, cancellation terms, and a signature with date

Digital vs. paper therapy intake forms

Paper intake forms get completed in the waiting room — rushed, half-legible, and retyped later. A digital therapy intake form is sent as a link before the first appointment, completed on the client’s phone at their own pace, signed electronically, and returned to you as a tidy PDF organized by section.

  • Completed before the visit — the first session starts on time with the history already read
  • Required fields — the form cannot be submitted half-finished, so no chasing missing answers
  • Conditional questions — the medication table only appears for clients who take medication
  • E-signature with an auto-filled signing date — no missed signature lines
  • Legible, organized responses — every intake arrives as the same clean, filed PDF

How to create a therapy intake form in 5 steps

  • Pick a starting template — choose the therapy intake template that matches your practice
  • Choose your sections — keep, remove, or reorder the pre-built clinical sections
  • Add your own questions — multiple choice, yes/no, or free text, marked required or optional
  • Brand it — upload your logo and show your practice name at the top
  • Deliver it — download the print-ready PDF, or send it digitally by email or text for e-signature

Frequently asked questions

›What is a therapy intake form?

A therapy intake form is the questionnaire a new client completes before starting therapy. It gathers contact details, presenting concerns, mental health and medical history, goals, and signed consent, so the therapist has a full starting picture before the first session.

›What questions should a therapy intake form ask?

Ask about the reason for seeking therapy, previous therapy experience, current medications, family and social background, substance use, sleep and mood, and goals for treatment - plus contact, emergency contact, and consent with a signature. The builder on this page includes all of these as ready-made sections.

›Can clients fill out the therapy intake form online?

Yes. Send the form as a link by email or text; the client completes and signs it on any device, and you receive the finished, signed PDF. You can also print a paper version of the same form.

›Can I add my own questions to the template?

Yes. You can add custom questions to any section, create whole custom sections, rename anything, and mark questions required or optional. Your logo and practice name are included too.

›Does the form support e-signatures?

Yes. Clients sign directly on the form on any device, the signing date fills in automatically, and the signed PDF is delivered back to you.

›How much does it cost to create a therapy intake form?

Building and previewing are free. A print-ready PDF or a one-time digital send to one client is a single $14.99 payment. To send the same form to unlimited clients, plans start at $19 per month.

›Do my clients need an account or an app?

No. Clients open the link in their browser, complete the form, and sign - no account, no app, nothing to install.