A counseling intake form collects information about a potential client so the counselor is able to make an assessment before they are hired. The form asks for details concerning the client’s personal and family information, physical and mental health, and past and present issues they need help with. The intake form is reviewed by the counselor before an initial consultation is scheduled so they have a better idea of how to assess and treat the client.

Confidentiality

A counselor is obligated to maintain client confidentiality with regard to any personal or medical information shared through 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 threat to themselves or others, child abuse/neglect, criminal investigations, etc.).

Personal Information

The client intake form collects the client’s personal information, such as their name, address, contact info, emergency contact info, date of birth, educational background, religious beliefs, relationship status, and current employment situation.

Medical History

A client’s medical history is an essential part of the form as it allows the counselor to assess their current physical and mental state before the first session. Furthermore, if the client is using medication, the counselor may need to adjust their treatment options to avoid contraindications.

Alcohol & Drug Use

When completing an intake form, clients are asked to share their drug and alcohol use. Understanding the severity of a client’s substance abuse will help the counselor determine what sort of care and treatment the client will need. While a counselor isn’t trained to treat the client medically, it’s helpful to have a full understanding of their current state.

Personal Issues

A large portion of the client intake form is dedicated to determining what personal issues the client is struggling with. If the counselor is aware of the main problems the client is suffering from, the initial counseling sessions will be more productive in working towards finding a solution or treatment for the client.

Family Concerns

Understanding a client’s family background can help in finding a solution to the issues they are dealing with. The form seeks to unearth any familial problems the client has, such as death, divorce, abuse, financial problems, or inadequate housing.

Therapy Goals

The client will have the opportunity to share their objectives for their counseling sessions. Knowing what the client wants to get out of their discussions will allow both client and counselor to set benchmarks for development, track their progress, and help motivate the client.

Counseling Intake Form