Therapy Intake Form Template – US

Disclaimer

The information provided is intended solely as a general example for intake procedures related to psychological or counseling services. It does not constitute legal or clinical advice and should not be relied upon as a substitute for consulting qualified professionals. Regulations and requirements may vary depending on jurisdiction, and adjustments may be necessary to ensure compliance with local standards. The use of this example is the user’s responsibility, and we accept no liability for any errors, omissions, or consequences arising from its use without proper review by a licensed practitioner or legal expert.

Please note: This is a sample Therapy Intake Form template for US-based practices, intended for illustrative purposes only. Actual forms should be tailored to specific needs and comply with applicable regulations.

Therapy Intake Form Sample – US Edition

Client Information:

Name: ________________________________________________
Date of Birth: ____________________________________________
Address: ________________________________________________
Phone Number: ____________________________________________
Email: _________________________________________________

Emergency Contact:

Name: ________________________________________________
Relationship: ____________________________________________
Phone Number: ____________________________________________

Medical and Mental Health History:

Please provide relevant medical and mental health history, including current medications and previous treatments: ________________________________________________

Reason for Seeking Therapy:

Briefly describe your main concerns and goals for therapy: ________________________________________________

Consent and Acknowledgment:

I acknowledge that the information provided is accurate and understand the limits of confidentiality under applicable laws. I consent to the therapy process and agree to the terms outlined.