Counseling Intake Form template

Please complete this intake form before your first counseling session.

Healthcare template · 12 fields (11 required) · ~3 min for respondents to complete · Free plan · No credit card · Fully customizable

Set up your counseling intake form

Please complete this intake form before your first counseling session.

Tell clients this form is not monitored for emergencies and list crisis resources such as 988. Use a HIPAA-appropriate setup and ask only what you need before the first session.

The form separates phone number, date of birth, type of counseling, what brings you to counseling? into labeled questions. Review the choices and required fields for your organization before sharing it.

Best practices

• Tell clients this form is not monitored for emergencies and list crisis resources such as 988. Use a HIPAA-appropriate setup and ask only what you need before the first session.
• Customize the phone number and date of birth questions to match your records and terminology.
• Name the team that reviews responses and explain what happens after submission. A requested date, service or approval is not automatically confirmed.
• Ask only for information needed for this step. Arrange any sensitive supporting documents through an appropriate private process.

Every field, explained

• Your full name (Name, required)
• Email address (Email, required)
• Phone number (Phone, required)
• Date of birth (Date, required)
• Type of counseling (Dropdown, required)
• What brings you to counseling? (Long text, required)
• Have you had counseling before? (Single choice, required)
• Current medications (optional) (Long text)
• Session format preference (Single choice, required)
• Days that work for you (Multiple choice, required)
• Emergency contact name and phone (Short text, required)
• Acknowledgment (Multiple choice, required)

Frequently asked questions

What does this counseling intake form template collect?

Alongside contact details, it asks for phone number, date of birth, type of counseling, what brings you to counseling?, have you had counseling before?, current medications (optional), session format preference, days that work for you, emergency contact name and phone, acknowledgment. You can rename questions, change choices and remove fields that your workflow does not need.

How should I use this counseling intake form form?

Tell clients this form is not monitored for emergencies and list crisis resources such as 988. Use a HIPAA-appropriate setup and ask only what you need before the first session.

Can I edit this form and print a copy?

Yes. Open an editable draft, adjust the questions, and review the preview before publishing. You can also use the template page’s print option. Publishing requires an account; the draft can be tried first.

Related templates

• Mental Health Intake Form — 9 fields
• Therapy Intake Form — 13 fields
• Coaching Intake Form — 12 fields

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