Updated on May 26th, 2023
A counseling intake form is a written assessment of a client’s mental, physical, and spiritual health information and is reviewed prior to an appointment. It commonly includes questions about the client’s family, current medication, and the issues that brought them to seek a counselor.
Confidentiality
A counselor is obligated to maintain client confidentiality with regard to any personal or medical information shared via an intake form.
There are a number of exceptions established by the HIPAA Privacy Rule (specifically § 164.512) where information can be divulged without consent (such as a person being a harm to themselves or others, child abuse/neglect, criminal investigations, etc.).
What’s Included? (Sample)
- Personal Information
- Background Information
- Employment Details
- Medical History
- Alcohol & Drug Use
- Personal Issues
- Family Concerns
- Therapy Goals
CLIENT INTAKE FORM
1. Personal Information
- Full Name: _____________________
- Contact details
- Address: _____________________
- E-Mail: _____________________
- Phone: _____________________
- Date of Birth: _____________________
- Gender Identity: _____________________
- Marital Status: _____________________
- Emergency Contact Person: _____________________
2. Background Information
- Ethnicity/race: _____________________
- Religion/spiritual beliefs: _____________________
- Highest level of education: _____________________
- Living status: _____________________
- Relationship status: _____________________
3. Employment Details
- Employer’s name: _____________________
- Occupation: _____________________
- Start Date: _____________________
4. Medical History
- Primary Care Physician
- Name: _____________________
- Phone: _____________________
- Address: _____________________
- Medical issues: _____________________
- Allergies: _____________________
- Medications: _____________________
- Previous counseling? _____________________
5. Alcohol & Drug Use
- Alcohol consumption: _____________________
- Drug usage: _____________________
- Smoking intake: _____________________
- Previous rehabilitation? _____________________
6. Personal Issues
- Reasons for seeking counseling: _____________________
- Describe when issues first appeared: _____________________
- Most concerning issue right now? _____________________
7. Family Concerns
- Describe your immediate family: _____________________
- Currently living together? _____________________
- Which family members concern you? _____________________
- Describe the concerns: _____________________
8. Therapy Goals
- Personal goals: _____________________
- Family goals: _____________________
- Other goals: _____________________