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Counseling Intake Form template

A free counseling intake form for private practice: presenting concerns, symptom checklist, goals, therapy history, a safety question with crisis resources, and session preferences.

Counseling Intake Form

If you are in crisis or thinking about harming yourself, call or text 988 (Suicide & Crisis Lifeline) or call 911. This form is not monitored in real time.

About you

Full name *

Preferred name and pronouns

Date of birth *

Phone number *

Is it OK to leave a voicemail at this number? *

Email address *

Emergency contact name and phone *

What brings you in

In your own words, what would you like help with? *

Which of these have you noticed recently? *

How much are these affecting your daily life? (0 = not at all, 10 = severely) *

What would you like to be different when therapy is done? *

History

Have you been in counseling or therapy before? *

What was helpful, or not helpful? *

Current medications, including any for mood or sleep

Primary care provider

Safety

In the past month, have you had thoughts of harming yourself or ending your life? *

Thank you for telling us. Your therapist will talk with you about this at your first session. If you are in danger now, call or text 988 or call 911.

Practical details

How would you like to meet? *

Payment *

Signature

The information above is accurate to the best of my knowledge *

Signature — type your full legal name *

Date signed *

What to include in a therapy intake form

  1. Preferred name and pronouns
  2. Voicemail permission
  3. Presenting concerns
  4. Symptom checklist
  5. Goals for therapy
  6. A safety question with 988
  7. Telehealth and payment preferences
What's included
  • Full name
  • Preferred name and pronouns
  • Date of birth
  • Phone number
  • Is it OK to leave a voicemail at this number?
  • Email address
  • Emergency contact name and phone
  • In your own words, what would you like help with?
  • Which of these have you noticed recently?
  • How much are these affecting your daily life? (0 = not at all, 10 = severely)
  • What would you like to be different when therapy is done?
  • Have you been in counseling or therapy before?
  • What was helpful, or not helpful?
  • Current medications, including any for mood or sleep
  • Primary care provider
  • In the past month, have you had thoughts of harming yourself or ending your life?
  • How would you like to meet?
  • Payment
  • The information above is accurate to the best of my knowledge
  • Signature — type your full legal name
  • Date signed
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This template is a starting point, not legal or medical advice, and using it does not by itself make your practice HIPAA compliant. To collect patient health information on TendForm, use the HIPAA plan with a signed Business Associate Agreement, and have your own counsel review consent and policy wording.