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What Info to Gather?
The information collected through a client intake form will be used by the service provider to understand the client’s background and assess their needs. Below are a few common sections that are included in client intake forms:
- Contact and personal information
- Emergency contact
- Medical history
- Education and employment background
- Reasons for seeking service
- Legal information
- Consent and release
Confidentiality
When a client provides personal and sensitive information on an intake form, the service provider generally has a duty to maintain the confidentiality of that information. However, the laws that govern the handling of this type of information change depending on the state in which the form is completed and the industry the professional works in.
For example, in the healthcare industry, the Health Insurance Portability and Accountability Act (HIPAA) sets standards for data collection by healthcare workers, while in the legal profession, the Model Rules of Professional Conduct aim to protect the gathering of client information through attorney-client privilege.
Sample
DISCLAIMER: Thank you for your interest in being a client of [ORGANIZATION’S NAME]. This form is used to collect information about new clients for internal purposes only and to be kept confidential.
| PERSONAL INFORMATION |
Name: ____________________ Gender: ☐ Male ☐ Female ☐ Other
Street Address: ________________________________________
City: ____________________ State: ____________________ Zip Code: ________
E-Mail: ____________________ Phone: ____________________
Date of Birth: ____/____/____ Ethnicity/Race: ____________________
Education: ☐ GED ☐ High School ☐ Bachelor’s ☐ Master’s
| SERVICE REQUEST |
What is the reason for seeking our services?
How did you hear about us? ________________________________________
| SIGNATURE |
Signature: _____________________________ Date: ____________________