free template

Client intake form template for therapists

A comprehensive intake form for Indian private practice — demographics, consent to contact, presenting concerns, history, and a gentle risk screen. Copy it as text, or print this page for a clean paper form.

To save as PDF: print this page (Ctrl/Cmd + P) and choose “Save as PDF” — only the template itself is printed.

Client Intake Form

Confidential — the information below helps your therapist understand you and plan your care. Leave blank anything you prefer to discuss in person.

1. Client details

Full name:  

Pronouns (optional):  

Date of birth (DD/MM/YYYY):  

Phone / WhatsApp number:  

Email:  

City & state of residence:  

Preferred language(s) for sessions:  

Occupation / area of study:  

Referred by (doctor, friend, online search — optional):  

2. Emergency contact

Please share one person we may contact if there is a serious and immediate concern for your safety. They will not be told anything about your therapy otherwise.

Name:  

Relationship to you:  

Phone number:  

I consent to this person being contacted in a safety emergency

  • Yes
  • Yes, but please try me first
  • I would like to discuss this in session

3. Consent to contact

You may contact me between sessions via (tick all that apply)

  • Phone call
  • WhatsApp message
  • SMS
  • Email

If I miss your call, you may

  • Leave a voicemail
  • Send a WhatsApp/SMS asking me to call back
  • Not leave any message

You may send me appointment reminders and invoices via

  • WhatsApp
  • Email
  • Both
  • Neither

4. Presenting concerns

What brings you to therapy at this time?

How long has this been a concern?:  

How much is it affecting your daily life right now? (0 = not at all, 10 = severely):  

What would you like to be different by the end of therapy?

5. Mental health & medical history

Have you been in counselling or therapy before?

  • No
  • Yes — it was helpful
  • Yes — it was not helpful

If yes: when, with whom, and what was the focus?

Are you currently taking any psychiatric medication?

  • No
  • Yes (please list below)

Current medications and prescribing doctor

Any medical conditions, ongoing treatment, or past hospitalisation we should know about?

Any family history of mental health concerns you consider relevant?

6. Safety

In the past month, have you had thoughts of harming yourself or ending your life?

  • No
  • Yes, occasionally
  • Yes, often
  • I would prefer to discuss this in session

Have you ever acted on such thoughts in the past?

  • No
  • Yes
  • I would prefer to discuss this in session

Is there anything else about your safety or living situation you want your therapist to know?

7. Practical details

Agreed fee per session (₹):  

Preferred session mode

  • In person
  • Online (video)
  • Either

Preferred days / times:  

8. Declaration

The information I have provided is accurate to the best of my knowledge. I understand it will be kept confidential by my therapist, subject to the limits of confidentiality explained in the informed consent form.

Client signature:  

Date:  

Disclaimer: this template is a starting point, not legal or medical advice. Adapt it to your practice and have a qualified professional — a lawyer, chartered accountant, or your clinical supervisor, as relevant — review it before you use it with clients.

How to use this template

Pair it with informed consent. This form collects information; it does not replace an informed consent form, which explains confidentiality and its limits before the client discloses anything.

Keep the risk section gentle.The safety questions include a “prefer to discuss in session” option deliberately — a form should open a conversation, not force a disclosure. Follow up verbally in the first session regardless of what is ticked.

Collect only what you need.Under India’s DPDP Act principles, less is more: every field here earns its place, and clients are told they can leave anything blank. If you add fields, ask yourself whether you truly need them.

Store it securely. Paper forms in a locked cabinet; digital copies in an encrypted, access-controlled system — not a shared family laptop or an open Google Drive folder.

The fee field deserves a policy behind it. Intake is the natural moment to state your fee and your cancellation terms — see our guides to setting therapy fees in India and a kind but firm no-show policy for what to put in those blanks.

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