Disclaimer
The information provided here is intended solely as a general example for documentation purposes. It is not specific medical advice or a substitute for professional clinical assessment. Users should consult qualified healthcare professionals for personalized guidance. Variations in individual circumstances and regional regulations may influence the appropriateness of this template. The use of this example is at the user’s own risk, and no liability is assumed for any inaccuracies or consequences resulting from its application without expert review.
Please note, this sample therapy intake form is provided for illustrative purposes only and may require adjustments to suit specific practice needs and regulations.
Therapy Intake Form Template
Client Information:
Name: ________________________________
Date of Birth: ________________________________
Address: ________________________________
Phone Number: ________________________________
Email: ________________________________
Emergency Contact:
Name: ________________________________
Relationship: ________________________________
Phone Number: ________________________________
Reason for Seeking Therapy:
Please briefly describe your reasons for seeking therapy and any specific issues you wish to address.
Medical and Mental Health History:
Please list any relevant medical or mental health conditions, current medications, and treatments you are receiving.
Consent:
I acknowledge that I have read and understand the privacy policy and voluntary nature of this therapy, and I agree to participate accordingly.
Signature: ________________________________
Date: ________________________________
Location: ______________________ Date: ______________________