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Counseling Intake Form

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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)

  1. Personal Information
  2. Background Information
  3. Employment Details
  4. Medical History
  5. Alcohol & Drug Use
  6. Personal Issues
  7. Family Concerns
  8. 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: _____________________