Healthcare

Therapy Intake Form Template

A therapy intake form is a form that collects a new client's contact details, reasons for seeking support, current symptoms, past mental health treatment, safety concerns and goals so a therapist can prepare for the first session and confirm the client is a good fit. This template uses plain, non-judgmental wording, keeps sensitive questions optional where it can, and ends with an informed consent statement covering confidentiality and its limits.

Use this template — freeTry it first
20 questions
4 pages
~5 min
To fill in
Classic layout
Mobile-ready
Free
No credit card
Therapy Intake form beside a photo of a therapist and client in a counseling session

Live preview · nothing you type is sent

Loading preview…

Photo by Vitaly Gariev on Pexels

Who it's for

Licensed therapists, counselors, psychologists, social workers in private practice, group practices and campus or employee counseling services.

  • Sending paperwork to a new client after the free consultation call
  • Screening referrals for a group practice before matching to a clinician
  • Intake for telehealth clients who never visit the office
  • University counseling centers handling student sign-ups at the start of term

What this template asks

Every question can be changed, removed or reordered once it's yours.

About you

  1. Full name*

    Short text

  2. Preferred name and pronouns

    Short text

    Optional

  3. Email*

    Email

  4. Phone number*

    Phone number

  5. Date of birth*

    Date

  6. Is it OK to leave a voicemail at this number?*

    Multiple choice

    • Yes
    • No, please text or email instead

  7. Emergency contact name*

    Short text

  8. Emergency contact phone*

    Phone number

What brings you here

  1. In your own words, what made you look for therapy now?*

    Long text

  2. Which of these have you noticed in the past month?

    Checkboxes

    • Low mood or sadness
    • Worry or anxiety
    • Panic attacks
    • Trouble sleeping
    • Changes in appetite
    • Anger or irritability
    • Grief or loss
    • Relationship problems
    • Stress at work or school
    • Trauma memories
    • Other

  3. How much are these affecting your daily life?*

    Multiple choice

    • A little
    • Somewhat
    • A lot
    • Severely

  4. Have you seen a therapist, counselor or psychiatrist before?*

    Multiple choice

    • Yes, currently
    • Yes, in the past
    • No, this is my first time

  5. Current medications for mental or physical health

    Long text

    Optional

Safety and wellbeing

  1. In the past two weeks, have you had thoughts of harming yourself or ending your life?*

    Multiple choice

    • No
    • Yes, in passing
    • Yes, often
    • Prefer to discuss in session

  2. How often do you drink alcohol or use recreational drugs?*

    Multiple choice

    • Never
    • Monthly or less
    • Weekly
    • Several times a week
    • Daily
    • Prefer not to say

  3. What would you like to be different after therapy?

    Long text

    Optional

Preferences and consent

  1. How would you like to meet?*

    Multiple choice

    • In person
    • Video
    • Phone
    • No preference

  2. When are you usually free?*

    Checkboxes

    • Weekday mornings
    • Weekday afternoons
    • Weekday evenings
    • Weekends

  3. Informed consent*

    Checkboxes

    • I have read and understand the confidentiality statement and agree to begin therapy

  4. Type your full name to confirm*

    Short text

Tips for more responses

  1. 1

    Require sign-in and one response per person so each client completes intake once and can save and come back later.

  2. 2

    Turn on email notifications so you see answers to the safety questions as soon as a form arrives, not on the day of the session.

  3. 3

    Use a PDF template to turn each completed intake into a tidy file for the client's record.

Questions

What should a therapy intake form include?

Contact and emergency contact details, the main reason the client is seeking therapy, current symptoms and how long they have lasted, past therapy or psychiatric treatment, current medications, a safety question about thoughts of self-harm, substance use, goals for therapy, session preferences, and informed consent covering confidentiality and its limits.

Should I ask about suicidal thoughts on an intake form?

Many clinicians include a short safety question so they can follow up at the first session, but a form is not a crisis service. Tell clients clearly who to contact in an emergency, and review safety answers promptly; this template includes that wording.

Is an online therapy intake form private?

Responses are kept in your private account and are not shown publicly. Rules for mental health records vary by country and state, so check your local health-privacy and licensing requirements before you collect client information online.

How long should a therapy intake form be?

Long enough to prepare for the first session, short enough to finish in about 10 to 15 minutes. Leave detailed history for the session itself and mark deeper questions as optional.

Is this therapy intake template free?

Yes. Copy it into a free Dculus Forms account, change anything you like and start collecting responses. No credit card is needed.

Can I change the questions?

Yes. Your copy opens in the form builder, where you can add, remove and reorder questions, change the layout and add your own branding.

Where do the responses go?

Responses arrive in your Dculus Forms workspace. You can export them to Excel or CSV, send them to Google Sheets or a webhook, and get email notifications.

Can I host it myself?

Yes. Dculus Forms is open source (GPLv3), so you can run it on your own servers and keep every response in your own database.

Similar templates

All templates
Use this template — free