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Therapist Client Intake Form

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Updated on July 4th, 2023

A therapist client intake form collects a new client’s information to ensure a therapist has the necessary details to develop a treatment plan. The document covers the client’s symptoms, age, gender, ethnicity, personal and family health history, and the concerns that have brought them to the clinic. Completing the form is an important first step in ensuring the therapist can quickly and successfully address the client’s needs.

CONTENTS

Sample

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THERAPIST CLIENT INTAKE FORM

DISCLAIMER: Thank you for your interest in being a client of [CLINIC NAME]. This form is used to collect information about new clients and used for internal purposes only. The information you provide is confidential and will be treated accordingly.

CLIENT INFORMATION

Name: __________________ Birth Date: _______ Address: ____________________
Phone: ____________________ Is it okay to: ☐ Phone? ☐ Leave a message? ☐ Text?
Email: ___________________________ (Emails may not be confidential)

DEMOGRAPHIC INFORMATION

Gender: ☐ Female ☐ Male ☐ Transgender ☐ Other (specify) ____________________
Ethnicity: _____________________  ☐ Prefer not to answer
Sexual orientation: ☐ Bisexual ☐ Heterosexual ☐ Lesbian/gay ☐ Other
Relationship status: ☐ Single ☐ Partnered ☐ Married ☐ Separated ☐ Divorced
☐ Widowed ☐ Other (specify) ___________
Check the highest degree you’ve earned: ☐ GED ☐ High school
☐ Associate’s degree ☐ Bachelor’s degree ☐ Master’s degree ☐ Doctoral degree

HEALTH HISTORY

Primary care physician name: ______________________________
How is your physical health? ☐ Poor ☐ Unsatisfactory ☐ Satisfactory ☐ Excellent
Do you take medications, over-the-counter drugs, or supplements? ☐ Yes ☐ No
Have you ever been assessed for psychological or learning issues? ☐ Yes ☐ No
-If yes, please explain, including when and by whom, and the findings/diagnosis:
____________________________________________________________
Have you been prescribed psychiatric medication in the past? ☐ Yes ☐ No
-If yes, please list what medications, the dosage, and when taken:
____________________________________________________________
Have you ever been hospitalized for psychiatric reasons? ☐ Yes ☐ No

FAMILY AND SOCIAL INFORMATION

List the family members to whom you are close:
____________________________________________________________
Any family history of mental illness, substance abuse, or learning difficulties? ☐ Yes ☐ No

PRESENTING CONCERNS

Briefly describe what brings you to this clinic:
____________________________________________________________
Approximately how long have these concerns been bothering you?
☐ A week ☐ A month ☐ Few months ☐ A year ☐ Few years ☐ Most of my life
How much do these concerns interfere with your:
Daily routine: Very little – ☐ 1 ☐ 2 ☐ 3 ☐ 4 ☐ 5 – Severely
Emotional well-being: Very little – ☐ 1 ☐ 2 ☐ 3 ☐ 4 ☐ 5 – Severely
Relationships/activities: Very little – ☐ 1 ☐ 2 ☐ 3 ☐ 4 ☐ 5 – Severely

ACKNOWLEDGMENT

Signature: _________________________ Date: ___________
Printed Name: ____________________

Guardian Signature (if required): ________________________ Date: ___________
Printed Name: ____________________

Minors in Therapy

The age of consent for therapy varies from state to state. Generally, patients must be at least 18 years old to consent to therapy, though exceptions are made for substance abuse treatment, minors in dangerous situations, and those serving in the military. Some states allow minors aged 12 or older to consent to therapy, provided their parents are notified, unless doing so would be adverse to the minor’s well-being.

Therapist Confidentiality

The confidentiality of clients’ information is protected by state and federal laws, including the HIPAA (Health Insurance Portability and Accountability Act). This act protects information such as a patient’s demographic data, mental health information, and their treatment. Protected information may only be disclosed if necessary for payments, patient treatment, and healthcare activities.

That said, clinics may disclose confidential patient information if the patient consents, if required by law enforcement, or to prevent an immediate threat to the patient or others.