Therapist/Counselor Intake Form
Confidential mental health intake with insurance info, assessment questions, consent forms, and HIPAA compliance
17
Fields
10-12
Minutes to complete
Advanced
Difficulty
Free
Template cost
Features used
Form fields
This template includes 17 fields. All fields are fully customizable.
Full Legal Name
RequiredPreferred Name
Date of Birth
RequiredPreferred Pronouns
Best Phone Number
RequiredEmail Address
RequiredHome Address
RequiredEmergency Contact Name
RequiredEmergency Contact Phone
RequiredRelationship to Emergency Contact
RequiredInsurance Provider
Leave blank if self-pay
Insurance Member ID
Session Preference
RequiredWhat brings you to therapy?
RequiredThis information is confidential
Have you been in therapy before?
Current Medications
List any psychiatric or other relevant medications
I have read and agree to the informed consent for treatment
RequiredI understand my rights, confidentiality limits, fees, and cancellation policy
Common use cases
New Client Intake
Mental Health Assessment
Therapy Onboarding
Industries
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