Psychotherapy Client Intake Form

Information you will need

• Do you want to upload the Clinic's logo? af image
• CLINIC ONLY: What’s your name or the name of your clinic?
• CLIENT ONLY: What’s your name?
• What’s your birthdate?
• What's your age?
• What's your marital status?
• How many children do you have?
• How old are your children?
• What's your address?
• What's your phone number?
• May the clinic leave a message?
• What's your email?
• May the clinic email you?
• Who's your emergency contact?
• What's the emergency contact's phone number?
• Are you receiving any mental health services?
• Why are you changing mental health services?
• Are you taking psychiatric medication?
• What medication are you taking?
• Have you been prescribed psychiatric medication before?
• What psychiatric medication were you prescribed?
• Have you received psychiatric hospitalization?
• Where and when were you hospitalized?
• What's your primary care physician's name, address, and phone number?

…and 99 more fields in the PDF.

Completed by the client.

The form includes 1 signature line, a notary acknowledgment.