free tool
Therapy intake form builder
Tick the sections you want and the form below fills in with wording from our intake guide. A good intake form takes a client ten to fifteen minutes and tells you who is coming, why now, what support they have had, and whether anything needs attention before you meet. Print it, download a PDF or copy the text into your own document. Nothing you type leaves your browser.
INTAKE FORM
This helps me plan our first session. It takes about ten to fifteen minutes. Leave out anything you would rather talk about in person.
1. About you
Full name: ____________________________
Name you would like me to use: ____________________________
Pronouns (optional): ____________________________
Date of birth: ____________________________
Email: ____________________________
Phone: ____________________________
City you will usually join sessions from: ____________________________
Occupation or studies: ____________________________
How should I contact you about appointments? Is it all right to leave a message, and is anyone else likely to see messages on this phone?
____________________________
____________________________
2. Emergency contact
Someone I can contact only if I am seriously worried about your safety and can't reach you. I won't contact them for any other reason without asking you first.
Name: ____________________________
Relationship to you: ____________________________
Phone number: ____________________________
3. What brings you here
What would you like help with? Write as much or as little as you like.:
____________________________
____________________________
____________________________
____________________________
Which of these feel relevant right now? (tick all that apply)
☐ Stress or worry
☐ Low mood
☐ Relationships or family
☐ Work or studies
☐ Grief
☐ Sleep
☐ Self-esteem
☐ Something else
How much are these concerns affecting your daily life? (0 = not at all, 10 = a great deal): ____________________________
What would you like to be different after therapy?
____________________________
____________________________
____________________________
4. Previous support
Have you seen a therapist, counsellor or psychiatrist before? When, for how long, and what helped or didn't?
____________________________
____________________________
____________________________
5. Current medication
Are you currently taking any medication? If so, which, and who prescribes it?
____________________________
____________________________
6. Health and history
Any physical health conditions I should know about?
____________________________
____________________________
Have you ever been admitted to hospital for your mental health?
○ No
○ Yes
Is there anything difficult from your past you would like me to know about before we meet? You don’t need to give details here.
○ No
○ Yes
7. Practical details
Preferred days and times: ____________________________
Sessions
○ In person
○ Online
○ Either
Preferred language for sessions: ____________________________
How did you find me? ____________________________
8. Declaration
Please tick to confirm (tick all that apply)
☐ The information I have given is accurate to the best of my knowledge.
☐ I understand it will be kept confidential, within the limits explained in the consent form, and used only to plan and provide my therapy.
Client signature: ____________________________ Date: ______________
What to keep for the room
Some topics need tone, pacing and a follow-up question, which a form can't give. Details of trauma or abuse, alcohol and drug use, sexual history and family conflict are better asked in session. The form only asks whether there is anything difficult from the past the client wants you to know about, and leaves it at yes or no.
PHQ-9 and GAD-7
Both are short self-report questionnaires, and the official PHQ Screeners site says they are free to download and use. They help when low mood or anxiety is plausibly part of the picture and you plan to repeat them to see whether things are changing. For couples work or a career decision they add little. A score is not a diagnosis, and both were validated in US primary care, so check that any translated version you hand a client has been properly studied.
Collect less
Under the DPDP Act, consent must be limited to the personal data the purpose needs, so every question you cut is data you don't have to protect. Keep confidentiality, fees and online-session terms in a separate consent form; the consent form generator builds one. For couples, send each partner their own copy.
The sections and wording follow our guide to therapy intake forms. There is also a fixed client intake form template, and two more free tools: the invoice generator and the fee calculator.
Send it as a link: try Therapy Manager free
Therapy Manager has an intake template built into Forms, with the emergency contact, concerns, the distress scale and the risk question. Send it as a link before the first session and the answers arrive in the client's record instead of your inbox.
Try Therapy Manager free