Psychotherapy Client Intake Form

Create Document

A psychotherapy client intake form is used by therapists to record a new patient’s information, mental health history, and condition. It will also collect past treatments, family history, previous diagnoses, and medication. The form helps the psychotherapist understand the individual’s case and assess what treatment to provide.

Psychotherapy Client Intake Form

A psychotherapy client intake form is used by therapists to record a new patient’s information, mental health history, and condition. It will also collect past treatments, family history, previous diagnoses, and medication. The form helps the psychotherapist understand the individual’s case and assess what treatment to provide.

Create Document
PDF
Word (.docx)
OpenDocument
PDF
Word (.docx)
OpenDocument

Last updated October 16th, 2024

Document Preview

A psychotherapy client intake form is used by therapists to record a new patient’s information, mental health history, and condition. It will also collect past treatments, family history, previous diagnoses, and medication. The form helps the psychotherapist understand the individual’s case and assess what treatment to provide.

Downloads: 1,492
  1. Home »
  2. Client Intake Forms »
  3. Psychotherapy

What’s Included

  • Personal information – The client’s details, contact information, and treatment history.
  • General health information – The client’s current physical health, sleep, lifestyle, and alcohol or substance use.
  • Symptoms – The mental health issues requiring treatment.
  • Family mental health history – Information on previous mental health diagnoses in the client’s family.
  • Personal details – The client’s strengths, coping strategies, and therapy goals.
  • Acknowledgment -The client’s signature, and if applicable, that of their guardian.

Protected Health Information (PHI)

The HIPAA (Health Insurance Portability and Accountability Act) protects a client or patient’s information during intake and treatment.[1] Certain exceptions apply, such as:

  • If the patient consents to their information being shared.
  • If the information is required for payments, treatments, and healthcare operations.
  • If it is necessary for preventing harm to the patient or others.
  • If disclosing the information is required to comply with a legal investigation.

Furthermore, the SAMHSA’s (Substance Abuse and Mental Health Services Administration) confidentiality regulations provide additional protections for a patient’s substance abuse records and treatment.[2]

Sources

  1. CDC – Health Insurance Portability and Accountability Act of 1996 (HIPAA)
  2. SAMHSA – Substance Use Confidentiality Regulations