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Client Intake Form for Mental and Emotional Wellness

Client Information

First Name

Last Name

Preferred Name (if different)

Date of Birth

Gender

Pronouns

Phone Number

Email Address

Preferred Method of Contact

Street Address

City/Suburb

State/Province

Postal/Zip Code

Emergency Contact

First Name

Last Name

Phone Number

Relationship

Physician

Primary Care

Phone Number

Therapy Services Offered

Please check the services you are interested in

 

Individual Therapy:

Cognitive Behavioral Therapy (CBT)

Dialectical Behavior Therapy (DBT)

Psychodynamic Therapy

Trauma-Focused Therapy

Mindfulness-Based Therapy

Solution-Focused Brief Therapy

Other:

Group Therapy:

Support Groups (e.g., grief, anxiety, depression)

Skill-Building Groups (e.g., stress management, communication skills)

Process-Oriented Groups (e.g., emotional exploration, interpersonal dynamics)

Specialty Groups (e.g., addiction recovery, LGBTQ+ support)

Other:

Other Services:

Couples/Family Therapy

Workshops (e.g., mindfulness, emotional regulation)

Psychoeducational Sessions

Other:

Client Background and History

What brings you to therapy at this time?

Have you attended therapy or counseling before?

If yes, please describe.

Have you ever experienced

Anxiety

Depression

Stress

Grief/Loss

Trauma/PTSD

Relationship Issues

Self-Esteem

Anger Management

Substance Use

Eating Disorders

Sleep Issues

Other:

How long have you been experiencing these concerns?

What are your goals for therapy?

Suitability for Individual or Group Therapy

Do you feel comfortable sharing your experiences in a group setting?

Yes

No

Unsure

What are your preferences for therapy?

One-on-one sessions

Group sessions

A combination of both

Are there any concerns or barriers that might affect your participation in therapy? (e.g., scheduling, transportation, financial constraints)

Do you have any past experiences with group therapy?

If yes, how was your experience?

What support systems do you currently have in place? (e.g., family, friends, community)

Mental Health History

Have you ever been diagnosed with a mental health condition?

If yes, please specify,

Are you currently taking any medications for mental health?

If yes, please list them.

Have you ever been hospitalized for mental health reasons?

If yes, please describe.

Do you have a history of self-harm or suicidal thoughts?

If yes, please describe.

Lifestyle and Self-Care

How would you describe your current lifestyle?

Balanced

Stressful

Isolated

Other:

What self-care practices do you currently engage in?

Do you use any substances (e.g., alcohol, drugs)?

If yes, please describe.

Consent and Agreement

Do you understand the confidentiality policies of this practice?

Do you consent to participate in therapy services?

Do you have any questions or concerns about the therapy process?

 

Client Signature

Client Intake Form Insights

Please remove this client intake form insights section before publishing.


This Form is a comprehensive tool designed to gather critical information about a client’s mental health history, current concerns, and preferences for therapy. It serves as a foundation for building a therapeutic relationship and tailoring services to meet the client’s unique needs. Below is an insight into the purpose, structure, and significance of each section of the form:


1. Client Information

  • Purpose: Collects basic demographic and contact details to establish communication and identify the client.
  • Insight: This section ensures the therapist can reach the client and address them respectfully (e.g., using preferred names and pronouns). It also includes emergency contact information for safety purposes.

2. Therapy Services Offered

  • Purpose: Provides an overview of available services and allows the client to indicate their interests.
  • Insight: This section helps the therapist understand what the client is seeking and whether their expectations align with the services offered. It also introduces the client to different therapeutic modalities, which they may not have been aware of.

3. Client Background and History

  • Purpose: Explores the client’s reasons for seeking therapy, their goals, and the duration and nature of their concerns.
  • Insight: This section is crucial for understanding the client’s presenting issues and what they hope to achieve. It helps the therapist identify patterns, prioritize concerns, and develop a treatment plan.

4. Suitability for Individual or Group Therapy

  • Purpose: Assesses the client’s comfort level with different therapy formats and identifies potential barriers to participation.
  • Insight: This section helps determine whether individual or group therapy (or a combination) is most appropriate for the client. It also highlights practical considerations, such as scheduling or financial constraints, that may impact their ability to engage in therapy.

5. Mental Health History

  • Purpose: Gathers information about past diagnoses, treatments, hospitalizations, and any history of self-harm or suicidal ideation.
  • Insight: This section provides context for the client’s current mental health status and helps the therapist assess risk factors. It also informs the therapist about past interventions that may or may not have been effective.

6. Lifestyle and Self-Care

  • Purpose: Explores the client’s daily habits, support systems, and substance use.
  • Insight: This section offers a holistic view of the client’s life, including factors that may contribute to or alleviate their mental health concerns. It also helps identify areas where the client may need additional support or resources.

7. Consent and Agreement

  • Purpose: Ensures the client understands confidentiality policies and consents to participate in therapy.
  • Insight: This section establishes trust and transparency by clearly outlining the client’s rights and responsibilities. It also provides an opportunity for the client to ask questions or voice concerns before beginning therapy.

8. Therapist’s Notes

  • Purpose: Allows the therapist to document initial impressions, recommendations, and next steps.
  • Insight: This section is critical for guiding the therapeutic process. It ensures the therapist has a clear plan for addressing the client’s needs and can track progress over time.

Key Benefits of the Form

  1. Comprehensive Assessment: The form covers a wide range of topics, ensuring no critical information is overlooked.
  2. Client-Centered Approach: By asking about preferences and goals, the form ensures the therapy is tailored to the client’s needs.
  3. Risk Assessment: Questions about mental health history and self-harm help the therapist identify potential risks and safety concerns.
  4. Therapeutic Alignment: The form helps match the client with the most appropriate services, whether individual, group, or a combination.
  5. Documentation: It provides a structured record of the client’s background and concerns, which can be referenced throughout the therapeutic process.

How to Use the Form Effectively

  • For Therapists: Use the form as a starting point for discussions during the initial session. Clarify any ambiguous responses and explore areas that require deeper understanding.
  • For Clients: Encourage clients to answer honestly and thoroughly. Assure them that their responses will help create a personalized and effective therapy plan.

This intake form is a vital tool for fostering a collaborative and effective therapeutic relationship, ensuring that both client and therapist are aligned in their goals and expectations.


 

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