Unlock hundreds more features
Save your Form to the Dashboard
View and Export Results
Use AI to Create Forms and Analyse Results

Forgot Password?
Get Started
OR
Sign UpLogin With Facebook
Sign UpLogin With Google

Psychotherapy Intake Form Template

Simplify your client onboarding with our easy-to-use template

Completing paperwork can be a daunting start for new therapy clients. This psychotherapy intake form template is designed to streamline the process, helping you gather essential client information quickly and efficiently. By using this form, you can enhance the client experience, ensure compliance with privacy regulations, and provide a comprehensive overview of client needs-all while saving valuable time. Customize it to fit your practice and easily share it online or in your office. Check out the live template to see how it works!

Use this Template (FREE) Live Preview
Full name
Date of birth
If you prefer to self-describe your gender, please specify
Pronouns (optional)
Email address
Mobile phone number
Address
Gender identity
Woman
Man
Non-binary
Prefer to self-describe
Prefer not to say
Emergency contact full name
Relationship to you
Emergency contact phone
May we contact this person in an emergency?
Yes
No
Insurance provider
Member ID or policy number
Will you be using insurance for payment?
Yes
No
What brings you to therapy at this time?
What are your primary goals for therapy?
How long has this been a concern?
Less than 2 weeks
2 to 8 weeks
2 to 6 months
6 to 12 months
Over a year
Not sure
Any past mental health diagnoses or conditions (optional)
Do you currently have a psychiatrist or medication prescriber?
Yes
No
Please list current medications, doses, and prescriber
Are you currently taking any psychiatric medications?
Yes
No
Medication allergies or other allergies
Do you have any significant medical conditions?
Please Specify:
Are you currently at risk of harming yourself?
Yes
No
Have you ever attempted suicide or engaged in self-harm?
Yes
No
In the past month, have you had thoughts of harming someone else?
Yes
No
Safety concerns or triggers you want your therapist to know
Do you have access to firearms or other lethal means?
Yes
No
Prefer not to say
Substances used in the past 12 months (select all that apply)
Alcohol
Cannabis
Nicotine or tobacco
Opioids
Stimulants
Sedatives or benzodiazepines
Hallucinogens
None
Other
Please Specify:
Have you ever received treatment for substance use?
Yes
No
How satisfied are you with your sleep?
Very dissatisfied
Dissatisfied
Neutral
Satisfied
Very satisfied
Current major stressors
I have supportive people I can rely on
Strongly disagree
Disagree
Neither agree nor disagree
Agree
Strongly agree
Preferred language for sessions
Accessibility needs or accommodations
Therapist preferences (optional)
Woman therapist
Man therapist
Non-binary therapist
LGBTQ+ affirming
Trauma-informed
Culturally responsive
No preference
Other
Please Specify:
Preferred session format
In person
Video
Phone
No preference
Preferred days
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Anything else about your availability we should know?
How may we contact you for scheduling and reminders? (select all that apply)
Email
Text message
Phone call
Do not contact
I have read and agree to the informed consent for treatment
Yes
No
I acknowledge receipt of the Notice of Privacy Practices (HIPAA)
Yes
No
I understand the financial responsibility and cancellation policy
Yes
No
Type your full name as your signature
Date
I consent to receive telehealth services when applicable
Yes
No
{"name":"Full name", "url":"https://www.quiz-maker.com/QPREVIEW","txt":"Full name, Date of birth, If you prefer to self-describe your gender, please specify","img":"https://www.quiz-maker.com/3012/images/ogquiz.png"}
Paper art illustration representing a psychotherapy intake form for an article on FormCreatorAI.

When to use this form

Use this form when onboarding new clients in private practice, group clinics, or telehealth. It captures demographics, presenting concerns, risk, history, medications, and consent. Send it before a first appointment, when restarting care, or to prepare a focused intake for trauma, anxiety, or mood issues. For couples or households, pair it with a Family therapy intake form. If you track progress between appointments, follow up with a Session check-in form. For clients referred after accidents or legal cases, route them to the Personal injury intake form. The result: you get a clear baseline, safer care, and a plan you can act on in the first visit.

Must Ask Psychotherapy Intake Questions

  1. What brings you to therapy now, and what are your top 12 goals for the next 90 days?

    This focuses the first session and sets clear outcomes you can measure. It helps you choose interventions that match the clients priorities instead of guessing.

  2. Are you having thoughts of harming yourself or others, or any recent self-harm?

    Screening for risk ensures urgent safety steps, referrals, or crisis planning happen right away. It also documents your duty-of-care decisions clearly.

  3. How are your symptoms affecting sleep, work, relationships, and daily routines, and for how long?

    Impact and duration show severity and urgency, guiding level of care. You can use these details as a baseline to track change over time.

  4. What mental health care have you tried before, and what medications or diagnoses do you have?

    Past treatment results help you avoid repeating what did not work and double down on what did. Medication and diagnosis history informs coordination with prescribers.

  5. Do you have medical conditions, pain, or injuries, and are you in other care right now?

    Co-occurring health issues can shape mood, energy, and treatment choices, so you should plan with the full picture. In integrated clinics, aligning with a Physical therapy intake form reduces duplicate questions and supports coordinated care.

More Forms

Copy/Edit Form Send to Recipients Make a Form w/AI Form Builder Must Ask Questions
  • 100% Free - No Catches
  • Collect Responses Today
  • Tailor to your Look & Feel