Psychotherapy Intake Form Template – US

Important Notice

The information collected in this preliminary intake document is intended solely for initial assessment purposes and does not establish a therapist-client relationship. It is not a substitute for comprehensive clinical evaluation or professional diagnosis. Confidentiality is maintained in accordance with applicable laws, but users should be aware of limitations regarding privacy and data security. Completing this form indicates acknowledgment that the information provided will be used solely for therapeutic planning and consent purposes. The user bears responsibility for the accuracy of the details shared, and the practitioner assumes no liability for any misunderstandings or consequences resulting from incomplete or inaccurate information provided without prior consultation.

Please regard this as a sample Psychotherapy Intake Form for the US; content may vary depending on specific practices and state regulations.

Psychotherapy Intake Form – Sample Template

Client Information:

Name: _______________________________
Date of Birth: _____________________
Address: _________________________
Phone: __________________________
Email: ___________________________

Emergency Contact:

Name: _______________________________
Relationship: ______________________
Phone: ____________________________
Email: ____________________________

Presenting Concerns:

Please briefly describe the issues or reasons for seeking therapy:

______________________________________________________________

Medical and Mental Health History:

Please list any relevant medical conditions, medications, prior therapy experiences, or mental health diagnoses:

______________________________________________________________

Consent and Agreement:

I acknowledge that I have provided accurate information and consent to participate in psychotherapy sessions. I understand confidentiality, exceptions, and privacy policies outlined by the provider.

Signature: ____________________________ Date: _________________________

Therapist’s Name: ______________________________________

License Number: _____________________________________

Additional Notes or Instructions:

______________________________________________________________

Location, ________________________