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Let’s Get Started! Online Therapy Initial Assessment

I. Personal Information

First Name

Last Name

Date of Birth

Gender

Preferred Pronouns

Contact Information

Phone

Email Address

Street Address

Street Address Line 2

City/Suburb

State/Province

Postal/Zip Code

Emergency Contact

First Name

Last Name

Phone Number

Email Address

Relationship

II. Background Information

What brings you to therapy/counseling? (Please describe your concerns or goals):

Have you attended therapy or counseling before?

If yes, please describe:

Are you currently taking any medications?

If yes, please list:

Do you have a history of mental health diagnoses?

If yes, please specify:

Do you have any medical conditions that may impact your therapy?

If yes, please describe:

III. Therapy and Counseling Preferences

What type of therapy or counseling are you interested in? (Check all that apply):

Individual Therapy

Couples Therapy

Family Therapy

Group Therapy

Other (please specify):

Preferred therapeutic approach (if known):

Cognitive Behavioral Therapy (CBT)

Dialectical Behavior Therapy (DBT)

Psychodynamic Therapy

Humanistic Therapy

Solution-Focused Brief Therapy (SFBT)

Acceptance and Commitment Therapy (ACT)

Trauma-Focused Therapy

Mindfulness-Based Therapy

Art or Creative Therapy

Other (please specify):

Are you open to group therapy?

If yes, what type of group would you prefer?

Support Group

Skills-Based Group (e.g., DBT, CBT)

Process-Oriented Group

Other (please specify):

Do you have a preference for the therapist’s gender?

Male

Female

Non-Binary

No Preference

Other (please specify):

Do you have any cultural, religious, or spiritual considerations that should be taken into account?

If yes, please describe:

IV. Suitability Assessment

What are your primary goals for therapy? (Check all that apply):

Managing anxiety or stress

Overcoming depression

Improving relationships

Coping with trauma or PTSD

Managing anger

Building self-esteem

Developing coping skills

Other (please specify):

On a scale of 1 to 10 (1 = low, 10 = high), how would you rate your current level of distress?

Are you currently experiencing any of the following? (Check all that apply):

Suicidal thoughts

Self-harm behaviors

Substance abuse

Eating disorders

Panic attacks

Sleep disturbances

Other (please specify):

Do you have a safe and private space to participate in online therapy sessions?

Do you have access to reliable internet and a device for telehealth sessions?

Are there any barriers to attending therapy (e.g., time zone, scheduling, financial)?

If yes, please describe:

V. Additional Notes or Comments

Is there anything else you would like us to know before your first session?

VI. Consent and Agreement

I understand that telehealth services involve communication through electronic means and that confidentiality will be maintained to the fullest extent possible.

I consent to participate in therapy/counseling and understand that I can withdraw consent at any time.

I have read and understand the privacy policy and terms of service provided by this practice.

Signature

Client Intake Form Insights

Please remove this client intake form insights section before publishing.


This explanation highlights the purpose of each section, the rationale behind the questions, and how the information gathered can be used to tailor therapy and counseling services to the client’s needs.

Section 1: Personal Information

Purpose:
This section collects basic demographic and contact information to establish a client profile and ensure the therapist can communicate effectively with the client.

Key Insights:

  • Full Name, Date of Birth, and Gender: These details help the therapist address the client appropriately and understand any age- or gender-related considerations.
  • Preferred Pronouns: Ensures the therapist respects the client’s gender identity and fosters an inclusive environment.
  • Contact Information: Necessary for scheduling sessions and sending reminders.
  • Emergency Contact: Provides a safety net in case of crises or emergencies during therapy.

Section 2: Background Information

Purpose:
This section gathers historical and contextual information about the client’s mental health, medical history, and previous experiences with therapy.

Key Insights:

  • Reason for Seeking Therapy: Helps the therapist understand the client’s primary concerns and goals.
  • Previous Therapy Experience: Indicates whether the client has prior exposure to therapy, which can influence their expectations and comfort level.
  • Medications and Medical Conditions: Identifies potential interactions between therapy and medical treatments, ensuring a holistic approach to care.
  • Mental Health Diagnoses: Provides a baseline understanding of the client’s mental health history, which can guide treatment planning.

Section 3: Therapy and Counseling Preferences

Purpose:
This section explores the client’s preferences and expectations for therapy, including the type of therapy, therapeutic approach, and group vs. individual settings.

Key Insights:

  • Type of Therapy: Determines whether the client is seeking individual, couples, family, or group therapy, which helps match them with the appropriate service.
  • Preferred Therapeutic Approach: Identifies the client’s openness to specific modalities (e.g., CBT, DBT, psychodynamic therapy), allowing the therapist to tailor their methods.
  • Group Therapy Openness: Assesses the client’s comfort with group settings, which can be beneficial for peer support and skill-building.
  • Therapist Gender Preference: Ensures the client feels comfortable with their therapist, which is crucial for building trust.
  • Cultural, Religious, or Spiritual Considerations: Highlights any factors that may influence the client’s worldview or therapeutic needs, promoting culturally sensitive care.

Section 4: Suitability Assessment

Purpose:
This section evaluates the client’s current mental state, goals, and readiness for therapy, as well as any potential barriers to participation.

Key Insights:

  • Primary Goals for Therapy: Helps the therapist align their approach with the client’s objectives (e.g., managing anxiety, improving relationships).
  • Level of Distress: Provides a snapshot of the client’s emotional state, which can inform the urgency and intensity of interventions.
  • Current Symptoms: Identifies specific issues (e.g., suicidal thoughts, substance abuse) that may require immediate attention or specialized care.
  • Safe and Private Space for Online Therapy: Ensures the client can participate in sessions without interruptions or privacy concerns.
  • Access to Technology: Confirms the client has the necessary tools for telehealth sessions.
  • Barriers to Therapy: Highlights logistical or financial challenges that may need to be addressed to ensure consistent participation.

Section 5: Consent and Agreement

Purpose:
This section ensures the client understands the nature of telehealth services, their rights, and the therapist’s policies.

Key Insights:

  • Confidentiality Agreement: Reassures the client that their information will be kept private, fostering trust.
  • Consent to Participate: Confirms the client’s willingness to engage in therapy and acknowledges their right to withdraw consent at any time.
  • Privacy Policy and Terms of Service: Ensures the client is informed about the practice’s policies, promoting transparency.

Section 6: Additional Notes or Comments

Purpose:
This section provides an open-ended opportunity for the client to share any additional information that may be relevant to their care.

Key Insights:

  • Client’s Voice: Allows the client to express themselves freely, which can reveal important details not covered in the structured questions.
  • Therapist’s Understanding: Helps the therapist gain a more holistic view of the client’s needs and preferences.

How This Form Benefits the Client and Therapist

  1. For the Client:
    Ensures their needs and preferences are heard and respected.
    Helps them reflect on their goals and expectations for therapy.
    Provides a sense of safety and transparency about the therapeutic process.
  2. For the Therapist:
    Offers a comprehensive understanding of the client’s background, needs, and goals.
    Guides the selection of appropriate therapeutic approaches and modalities.
    Identifies potential challenges or barriers to therapy, allowing for proactive solutions.
    Builds a foundation of trust and rapport with the client.

Tailoring Therapy Based on the Intake Form

  • Matching Modalities: For example, a client with anxiety may benefit from CBT or mindfulness-based therapy, while someone with trauma may need trauma-focused therapy.
  • Group vs. Individual Therapy: Clients seeking peer support may thrive in group settings, while those with specific personal issues may prefer individual sessions.
  • Cultural Sensitivity: Therapists can adapt their approach to align with the client’s cultural, religious, or spiritual beliefs.
  • Crisis Management: Clients reporting suicidal thoughts or self-harm behaviors can be prioritized for immediate support and safety planning.

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