Client Intake Form

A confidential client record to help your therapist understand your needs before your first session.

Privacy First This form is completely confidential. You only need to share information you are comfortable providing, and everything you submit is protected by clinical ethics and encrypted transmission.

1. Client Information

Full Name

Preferred Name

Age

Gender

Phone Number

Location / City

Preferred Language

2. Reason for Seeking Support

What brings you to counseling at this time? (select all that apply)

Other (please specify)

Briefly describe what you would like support with

3. Mental & Emotional Well-Being

How have you been feeling recently?

Mostly okay Slightly distressed Moderately distressed Very distressed Extremely distressed

How much is this affecting your daily life?

Not much Somewhat Significantly Severely

4. Safety

If You're in Crisis Contact local emergency services right away or call our office directly. This form is not monitored in real time.

Are you currently having thoughts of harming yourself or ending your life?

No Yes Prefer to discuss privately

Are you currently experiencing thoughts of seriously harming someone else?

No Yes Prefer to discuss privately

Do you currently feel unsafe at home or in a relationship?

No Yes Unsure

5. Previous Support

Have you previously received counseling or mental health support?

No Yes

If yes, briefly state what type

Are you currently taking any medication or receiving treatment related to your mental health or substance use?

No Yes Prefer not to say

6. Support & Coping

Who or what do you turn to when you are going through a difficult time?

What would you like to achieve through counseling?

7. Consent & Confidentiality

I have read and agree to the consent & confidentiality statement above.

Full Name (as signature)

Date

Prefer to book your appointment first? Schedule a session and complete this form beforehand or during your intake call.