A therapy intake form is the packet a new counseling client completes before the first session: who they are, who to call in a crisis, what brings them in, the history you need, and their signed consent to how your practice works. This free template is written for a solo or small group private practice (LPC, LCSW, LMFT, psychologist) and bundles the intake questions with the consent, confidentiality and telehealth pieces most clinicians hand out together.

When should you use a therapy intake form instead of a general one?

Use this one when you provide counseling or psychotherapy. Our general patient intake form is built for physical care, like PT or chiropractic, and it doesn’t ask about mood, safety, prior therapy or substance use, or explain confidentiality limits the way a therapy client needs.

If you want a detailed consent document for a particular procedure or research study, pair this with an informed consent form. Plenty of practices keep a longer standalone informed consent and use the short summary in this intake as a signed acknowledgment of it.

What goes into a counseling intake form?

Here’s the order our template follows and why.

Client details and emergency contacts

Name, date of birth, pronouns if the client wants to share them, address, and how you may contact them. That last question matters in therapy more than anywhere: a client may not want a voicemail at home or a text that shows on a shared screen. The template asks which methods are okay and whether you can leave a message.

Two emergency contacts, and a checkbox giving permission to contact them in an emergency. Without that, you may have a phone number you can’t use.

Reason for seeking care and history

An open question in the client’s own words, then a few structured ones: prior therapy, psychiatric hospitalizations, current medications and prescriber, primary care provider, alcohol and drug use, and a short symptom checklist. Keep it short enough that a nervous client finishes it. You’ll learn more in the session anyway.

There’s a question about current safety (thoughts of harming self or others). Some clinicians prefer to ask that in person. If you keep it on the form, have a plan for what you’ll do if someone checks yes two days before the appointment.

A plain summary: what therapy involves, that it has benefits and risks, that the client can ask questions or stop at any time, and how long sessions last. The client initials that they’ve read your full informed consent document if you have one.

Limits of confidentiality

This is the paragraph clients remember later, so write it clearly. Federal privacy rules let a covered provider disclose information when it’s necessary to prevent or lessen a serious and imminent threat to someone’s health or safety, and to report child abuse or neglect to an authority that’s allowed by law to receive those reports. Whether you must warn or report, and in which situations (elder abuse, a court order, a named threat), comes from your state’s law and licensing board. Our template keeps it general with blanks for your state’s specifics. Don’t leave them blank.

A checkbox section for clients who’ll meet by video or phone: the platform, where the client should be during sessions, what happens if the connection drops, a backup phone number, and the client’s location in case of an emergency. Before you rely on it, read your licensing board’s telehealth rules, especially anything about seeing clients who are in another state.

Practice policies and privacy notice

Fees, cancellation window, how you handle late payments, and whether you bill insurance. Then an acknowledgment that the client received your notice of privacy practices. HHS says a covered provider with a direct treatment relationship must give the notice no later than the first service and make a good faith effort to get a written acknowledgment. When the first service is delivered electronically, the notice should go out electronically too.

Minors

HHS notes that state law decides the age at which a minor can consent to certain types of care and may add rules about what parents can see. So the template has a separate parent or guardian signature block. Use it, or delete it, based on your state and the client.

What about HIPAA and where the forms are stored?

Whether HIPAA applies depends on your practice. HHS says providers, including psychologists and other clinicians, are covered entities only if they transmit health information electronically in connection with a standard transaction, like electronic insurance billing. A cash-only therapist may not be covered. One who bills insurance electronically almost certainly is.

If you’re covered, anyone storing completed intakes for you (a form builder, cloud drive or e-signature service) needs a business associate agreement. SignWren is not set up to handle HIPAA-covered data and does not sign BAAs, so don’t use it for client intake in a covered practice.

How do you set up the intake form and get it signed?

  1. Put your practice name, license type and contact details at the top.
  2. Fill in your state’s specific confidentiality exceptions and your fees and cancellation policy. Hypothetically, if you charge $140 per session and a $70 fee for cancellations under 24 hours, say exactly that.
  3. Delete the telehealth section if you only see people in person.
  4. Send it with your privacy notice at least a day before the first session.
  5. Review it before the client arrives, especially the safety question.

Electronic signatures on intake paperwork are generally valid, as we explain in are electronic signatures legally binding. If you’re not a covered entity, download it, fill in the blanks, and send it with any e-signature tool you like.

This template is general information, not legal or clinical advice. For your own practice, check with your licensing board and a lawyer licensed in your state.