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Psychology Intake Form Template

Streamline patient assessments and improve client onboarding

Understanding your new patients can be challenging, especially when you need comprehensive data for effective treatment plans. Our psychology intake form is designed to help mental health professionals like you gather essential information swiftly and efficiently. Benefit from seamless patient onboarding, track mental health histories accurately, and maintain a professional appearance with customizable branding options. Plus, the form is accessible and WCAG-aligned to cater to all clients. You can start using this ready-to-go template today.

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Full name
Who is completing this form?
I am the client
I am the parent/guardian of the client
Other
Please Specify:
Date of birth
Pronouns
Gender identity
Woman
Man
Non-binary
Prefer to self-describe
Prefer not to say
Email address
Mobile phone number
Home address
Preferred contact method
Phone call
Text message
Email
No preference
Is it okay to leave a detailed voicemail?
Yes
No
Is it okay to send appointment-related text messages (SMS)?
Yes
No
Emergency contact full name
Emergency contact relationship to you
Emergency contact phone number
Insurance provider (if applicable)
Payment method
Insurance
Self-pay
Employee assistance program (EAP)
Not sure
Other
Please Specify:
Briefly describe your primary concerns
When did these concerns begin and how have they changed?
What are your main goals for therapy?
Have you received mental health treatment before?
Yes
No
Known mental health diagnoses (if any)
Current medications (include dose if known)
Medication or substance allergies
Types of care you have used (select all that apply)
Outpatient therapy
Psychiatry/medication management
Inpatient hospitalization
Partial hospitalization or IOP
School counseling
Support group
Crisis services
Not applicable
Other
Please Specify:
Little interest or pleasure in doing things
Never
Rarely
Sometimes
Often
Always
Feeling down, depressed, or hopeless
Never
Rarely
Sometimes
Often
Always
Feeling nervous, anxious, or on edge
Never
Rarely
Sometimes
Often
Always
Trouble falling or staying asleep, or sleeping too much
Never
Rarely
Sometimes
Often
Always
Thoughts that you would be better off dead or of hurting yourself
Never
Rarely
Sometimes
Often
Always
Are you currently having thoughts of harming yourself?
Yes
No
History related to suicide risk
Never
Past thoughts only
Past plan without attempt
Past attempt(s)
Prefer not to say
Do you feel safe at home?
Yes
No
Do you have access to firearms or other weapons at home?
Yes
No
How often do you drink alcohol?
Never
Monthly or less
2-4 times per month
2-3 times per week
4 or more times per week
Prefer not to say
Do you currently use tobacco or vape products?
Yes
No
Significant medical conditions or recent hospitalizations
Substances used (select all that apply)
Cannabis
Stimulants (e.g., cocaine, meth)
Opioids (non-prescribed)
Sedatives/benzodiazepines
Hallucinogens
None
Other
Please Specify:
Relationship status
Single
In a relationship
Married/Partnered
Separated/Divorced
Widowed
Prefer not to say
Current living situation
Alone
With family/partner
With roommates
Campus housing
Prefer not to say
Other
Please Specify:
Employment and/or school status (select all that apply)
Full-time employment
Part-time employment
Unemployed
Student
Homemaker
Retired
On leave/disabled
Other
Please Specify:
Current major stressors (select all that apply)
Please Specify:
Preferred session format
In-person
Video/telehealth
Phone
No preference
Scheduling availability (select all that apply)
Morning
Afternoon
Evening
Weekdays
Weekends
Accessibility needs or accommodations
Therapist preferences (select all that apply)
I consent to evaluation and treatment by the provider or clinic
Yes
No
I consent to receive services via telehealth when applicable
Yes
No
Signature (type your full legal name)
Date signed
I have reviewed the Notice of Privacy Practices (HIPAA) and acknowledge receipt
Yes
No
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Paper art illustration related to psychology intake form template and FormCreatorAI.

When to use this form

Use this intake when you onboard new clients for one-on-one therapy, telehealth, or assessments. Send it before the first session to capture presenting concerns, history, medications, risk, and goals so you can plan care and reduce time on paperwork. Solo practitioners can screen fit and match clients to the right modality; group practices can standardize questions across clinicians. If you work in counseling settings, compare with the Counseling intake form to tailor language and consent. Running groups? Pair this template with the Intake form for group sessions new client form to collect group-specific logistics and rules. For integrated clinics with care coordinators, align fields with your EHR or the Physical therapy intake form to keep records consistent.

Must Ask Psychology Intake Questions

  1. What brings you to therapy right now?

    This open question reveals the clients immediate concerns and priority goals. It helps you set the first-session agenda and choose a starting intervention.

  2. How long have these concerns been affecting your daily life, work, or relationships?

    Duration and impact show severity and urgency, which improves triage. You can tailor frequency and level of care based on how much functioning is disrupted.

  3. Are you currently taking any medications or receiving care from other providers?

    Knowing current treatment avoids interactions and duplication, and it supports coordinated care. If you also manage referrals or case management, see the Social worker intake form for complementary fields you might include.

  4. Have you experienced thoughts of harming yourself or others, or any recent crisis?

    Clear risk questions help you identify safety needs early. You can document a plan, involve supports, and escalate care when needed.

  5. What outcomes would you like to achieve in the next 4 to 8 sessions?

    Short-term goals make progress measurable and keep treatment focused. This also aligns expectations and improves engagement.

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