Client Intake Form -
Anxiety and Depression Support
Client Information
First Name
Last Name
Date of Birth
Gender
Contact Information
Street Address
Phone
Preferred Method of Contact
Emergency Contact
First Name
Last Name
Phone
Relationship
Background Information
What brings you to seek support today?
Anxiety
Depression
Both
Other:
How long have you been experiencing these challenges?
Less than 1 month
1-6 months
6-12 months
Over 1 year
Over 5 years
Have you received support for anxiety or depression before?
If yes, please describe.
Are you currently taking any medication for anxiety or depression?
If yes, please list.
Do you have a diagnosis from a healthcare professional?
If yes, please specify.
Symptoms and Challenges
What symptoms are you currently experiencing? (Check all that apply)
Anxiety Symptoms
Excessive worry
Racing thoughts
Panic attacks
Difficulty concentrating
Restlessness
Irritability
Sleep disturbances
Fatigue
Muscle tension
Avoidance of certain situations
Other:
Depression Symptoms
Persistent sadness
Loss of interest in activities
Feelings of hopelessness
Changes in appetite
Weight loss/gain
Sleep disturbances
Fatigue
Difficulty concentrating
Feelings of guilt or worthlessness
Thoughts of self-harm or suicide
Other:
On a scale of 1 to 10, where 1 is very mild and 10 is the most severe you can imagine, how would you rate the severity of your current symptoms?
Anxiety
Depression
Are there any specific triggers or situations that worsen your symptoms?
If yes, please describe.
Have you experienced any recent major life changes or stressors?
If yes, please describe.
Support Services and Preferences
What type of support are you seeking? (Check all that apply)
Individual Therapy
Group Therapy
Medication Management
Crisis Support
Mindfulness/Meditation
Lifestyle Coaching
Online Therapy
In-Person Therapy
Other (please specify):
What are your goals for seeking support?
Reduce symptoms of anxiety
Reduce symptoms of depression
Improve coping skills
Build a support network
Gain clarity and self-awareness
Other (please specify):
Do you have any preferences for the type of therapy or approach?
Cognitive Behavioral Therapy (CBT)
Dialectical Behavior Therapy (DBT)
Psychodynamic Therapy
Acceptance and Commitment Therapy (ACT)
Mindfulness-Based Therapy
Other (please specify):
Are you comfortable with virtual/online sessions?
Yes
No
Sometimes
Do you have any cultural, religious, or personal considerations that should be taken into account?
If yes, please describe.
Risk Assessment
Have you ever had thoughts of self-harm or suicide?
If yes, please describe.
Do you currently feel safe?
If no, please explain.
Do you have a safety plan in place?
Consent and Agreement
I understand that the information provided will be kept confidential and used to determine the most appropriate support services for me.
I consent to participate in the recommended services.
Additional Comments or Questions
Signature
Form Template Insight
Form Template Insight
Please remove this form template insight section before publishing.
Below is a detailed insight into the Anxiety and Depression Support Client Intake Form, explaining the purpose and importance of each section, as well as how it contributes to understanding the client’s needs and suitability for the services being offered.
1. Client Information
This section collects basic demographic and contact details to establish a record for the client and ensure effective communication.
Purpose:
- Identifies the client and ensures accurate record-keeping.
- Provides emergency contact information for safety purposes.
- Determines the preferred method of communication to respect the client’s comfort and accessibility.
2. Background Information
This section explores the client’s history with anxiety and depression, including previous support and diagnoses.
Purpose:
- Helps understand the duration and severity of the client’s challenges.
- Identifies whether the client has prior experience with therapy or medication, which can inform the approach to care.
- Determines if the client has a formal diagnosis, which can guide treatment planning.
3. Symptoms and Challenges
This section delves into the specific symptoms the client is experiencing and their severity.
Purpose:
- Provides a clear picture of the client’s mental health status.
- Helps differentiate between anxiety and depression symptoms, which may require different interventions.
- Identifies triggers or stressors that exacerbate symptoms, enabling targeted support.
- Assesses the impact of recent life changes, which may contribute to the client’s current state.
4. Support Services and Preferences
This section explores the client’s goals, preferences, and expectations for support.
Purpose:
- Identifies the type of support the client is seeking (e.g., therapy, medication management, lifestyle coaching).
- Clarifies the client’s goals, ensuring alignment between their expectations and the services offered.
- Determines preferences for therapeutic approaches (e.g., CBT, DBT) to tailor the intervention.
- Assesses comfort with virtual or in-person sessions, ensuring accessibility and convenience.
- Accounts for cultural, religious, or personal considerations to provide culturally sensitive care.
5. Risk Assessment
This section evaluates the client’s safety and risk of self-harm or suicide.
Purpose:
- Identifies immediate risks to the client’s safety, allowing for prompt intervention if needed.
- Determines if the client has a safety plan in place, which is critical for those at risk of self-harm or suicide.
- Ensures the client feels supported and safe during the intake process.
6. Consent and Agreement
This section ensures the client understands and agrees to the terms of service.
Purpose:
- Confirms the client’s understanding of confidentiality and how their information will be used.
- Obtains consent for participation in recommended services, ensuring ethical and legal compliance.
- Provides space for additional comments or questions, allowing the client to voice concerns or preferences.
7. Signature
This section formalizes the client’s agreement and the staff’s acknowledgment of the intake process.
Purpose:
- Documents the client’s consent and agreement to participate in services.
- Provides a record of the intake process for accountability and legal purposes.
How This Form Supports the Client and Service Provider
- Comprehensive Assessment: The form gathers detailed information about the client’s mental health history, symptoms, and preferences, enabling a holistic understanding of their needs.
- Personalized Care: By identifying the client’s goals, preferences, and cultural considerations, the form ensures that the services provided are tailored to their unique situation.
- Safety and Risk Management: The risk assessment section prioritizes the client’s safety, ensuring that immediate concerns are addressed promptly.
- Informed Decision-Making: The form empowers the client to make informed decisions about their care by clarifying the types of support available and obtaining their consent.
- Ethical and Legal Compliance: The consent and signature sections ensure that the service provider adheres to ethical and legal standards, protecting both the client and the organization.
Why This Form is Important
- For the Client: It provides a structured way to express their needs, concerns, and preferences, ensuring they feel heard and understood.
- For the Service Provider: It serves as a foundational tool for developing a personalized treatment plan and ensuring the client receives appropriate and effective support.
This form is a critical first step in building a trusting and collaborative relationship between the client and the service provider, ultimately leading to better outcomes for the client.
To configure an element, select it on the form.