Your intake form sets the foundation for your practice and the overarching themes of your therapeutic process. The intake serves as a structured initial point of contact, as this documentation captures your client’s presenting concerns, relevant demographic information, medical history, and other essential details. In addition, they also include your practice consent forms and confidentiality agreements.
From a more holistic framework, you can conceptualize your intake process as the main blueprint for starting treatment. It helps you begin the early treatment planning phase, and it gives your clients an overview of what to expect from your work with them. In this article, I’ll include the best legal and ethical practices for utilizing these forms.
Informed Consent
Clients must be able to consent to their treatment before beginning therapy with you. Having their written consent protects you legally, and it also cultivates a sense of trust and safety within the therapeutic relationship. You want to include the following elements in your informed consent:
Purpose of Therapy
Include information about the general process of psychotherapy and the theoretical modalities you may engage in. You should emphasize that therapy is collaborative and that you cannot guarantee any one specific outcome.
Risks and Benefits of Therapy
From the onset, it’s important for clients to understand the risks of therapy, which may include an initial increase in unwanted symptoms, feeling worse before you feel better, and difficulties measuring progress. Benefits may include increased insight into certain behavioral patterns, learning new coping skills, strengthening relationships, and improving emotional regulation.
Qualifications and Licenses
Include your credentials, licenses, and certifications if applicable. If you’re under supervision, indicate that clearly and include your supervisor’s name and credentials.
Confidentiality and Limits of Confidentiality
Review the measures you take to ensure confidentiality, including how you store records. Highlight the exceptions to confidentiality, which can vary by location, but generally include:
- Child abuse
- Elderly abuse
- Dependent adult abuse
- Grave risk of harming self or others
- Court orders by a judge
- When clients give written consent to disclose information
Office Policies
Indicate your specific logistics of therapy, including session length, fees, payment methods, and information about insurance billing (if applicable). Clearly state your cancellation and no-show policy, including the rate you charge if this occurs. Indicate how and when clients might be able to communicate with you between sessions. If you have emergency protocols in place, this is where you should list them.
Telehealth Considerations
Make sure you have a section indicating the benefits, risks, and logistics associated with telehealth. You need to mention privacy expectations and potential emergency protocols during these sessions.
Client Rights and Autonomy
Indicate that clients always have the right to end therapy at any time, and they have the right to access their records. Clarify specific client responsibilities, including the benefits of attending sessions on time and consistently.
Client Therapy Intake Form
It’s standard for clients to fill out an intake form indicating why they’re seeking therapy and what they’ve been experiencing before beginning treatment. This input can be invaluable, as it allows you to understand your client’s symptoms and the ways they have attempted to manage their circumstances in the past. Here is what you want to include:
Basic Demographic Information
- Client’s full name
- Client’s preferred name
- Date of birth
- Address
- Phone number and email
- Emergency contact and contact information
- Relationship status
- Living arrangements
- Place of employment
Presenting Concerns
This section specifically focuses on the particular issues that will be addressed in your course of therapy. It offers a first glimpse into why a client is seeking therapy and what they hope to achieve.
Consider combining structured symptom checklists with open-ended questions. Checklists can identify common symptoms and patterns across clients. They allow you to track the severity and duration of issues such as anxiety, depression, sleep disturbance, irritability, substance use, and interpersonal conflict. You might frame these with a timeframe (e.g., “In the past two weeks…”) or use rating scales (e.g., 0–4 for frequency or intensity).
I also recommend open-ended prompts, including:
- What are you seeking therapy for at this time?
- What is your main goal for therapy?
- How long have these concerns been impacting your well-being?
- What have you tried so far to manage these concerns? What has or hasn’t worked?
- Is there anything about therapy that you’re unsure of or worried about?
Mental Health History
It’s a good idea to assess a client’s past history with accessing mental health services. This will help you better understand what has been effective (or not effective) in other episodes of care.
You can include some open-ended questions like:
- Have you received counseling or therapy before? If so, what was your experience like?
- Have you ever been diagnosed with a mental health condition?
- Are you currently taking any psychiatric medications?
- Have you ever been hospitalized for a psychiatric concern?
Medical History
The mind and body are interconnected, and understanding this intersection is important for clinicians. You want to have an initial overview of any past or present physical health concerns. You might ask:
- Are you diagnosed with any medical disorders? If so, please list them and note when you were diagnosed.
- Please list medications and supplements you currently take. Include the reason, dosages, and how long you’ve been taking them.
- Do you currently drink alcohol or use any mind-altering substances? If yes, how often in what quantities? Do you have any concerns about your use?
- Have you ever had any significant surgeries or medical procedures? Please describe the type and approximate date.
- How often do you engage in physical activity?
- How would you describe your current sleep quantity and sleep quality?
Other Best Practices for Intake Forms
Keep Forms Concise
Ideally, you should keep your paperwork concise and to the point. Keep in mind that clients often feel anxious before starting therapy, and you want to be mindful of asking too many vulnerable or intrusive questions.
Complete Forms Before First Session
Ensure clients fill out these forms before the first session: You should not begin treatment until a client signs their paperwork. Spend some time reviewing their answers before you first meet. This will help you better understand the clinical situation and feel more prepared to meet with your client.
Ask Clarifying Questions in Session
Your first session should dive into the content described on the intake form. You want your client to have ample opportunity to update any information, correct any details, or explain certain parts with more clarity.
Update Forms Regularly
It’s a good idea to get in the habit of reviewing your forms at least once per year. Your practice policies will naturally evolve, and you want your paperwork to reflect any of those changes.
Retain Records Safely
Although specific laws vary, therapists are, on average, expected to maintain client records for 7 years. Intake forms are part of this record, so you should ensure that you have secure storage to both protect client confidentiality and adhere to this legal consideration.
Final Thoughts
Although documentation can sometimes feel like a necessary evil, the intake process represents such a crucial component of ethical and effective care. It lays the groundwork for client-centered, collaborative treatment. Thoughtfully-designed intake forms provide a strong clinical starting point, and they also foster trust and convey professionalism. Furthermore, they can offer clients a sense of structure and reassurance about the work ahead.
The intake process is more than just paperwork—it’s the first step in building a therapeutic relationship that honors your client’s autonomy while protecting both of you legally and ethically. By investing time in creating comprehensive, thoughtful intake forms, you’re setting the stage for more effective treatment outcomes and a stronger therapeutic alliance.
