Therapy Intake Form template

Please complete this intake form before your first therapy session.

Healthcare template · 13 fields (9 required) · ~3 min for respondents to complete · Free plan · No credit card · Fully customizable

Set up your therapy intake form

Please complete this intake form before your first therapy session.

Send before the first appointment and review it together in session. Use a HIPAA-appropriate setup, list crisis resources like 988, and say whether you accept insurance.

The form separates phone number, date of birth, pronouns (optional), what would you like help with? into labeled questions. Review the choices and required fields for your organization before sharing it.

Best practices

• Send before the first appointment and review it together in session. Use a HIPAA-appropriate setup, list crisis resources like 988, and say whether you accept insurance.
• 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)
• Pronouns (optional) (Short text)
• What would you like help with? (Multiple choice, required)
• Tell us a bit more about what's going on (optional) (Long text)
• Current medications and prescribing provider (optional) (Long text)
• How will you pay for sessions? (Single choice, required)
• Insurance provider (if using insurance) (Short text)
• Preferred session type (Single choice, required)
• Emergency contact name and phone (Short text, required)
• Confirmation (Multiple choice, required)

Frequently asked questions

What does this therapy intake form template collect?

Alongside contact details, it asks for phone number, date of birth, pronouns (optional), what would you like help with?, tell us a bit more about what's going on (optional), current medications and prescribing provider (optional), how will you pay for sessions?, insurance provider (if using insurance), preferred session type, emergency contact name and phone, confirmation. You can rename questions, change choices and remove fields that your workflow does not need.

How should I use this therapy intake form form?

Send before the first appointment and review it together in session. Use a HIPAA-appropriate setup, list crisis resources like 988, and say whether you accept insurance.

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
• Counseling Intake Form — 12 fields
• Telehealth Intake Form — 13 fields

Customize this form — opens an editable draft, no account needed — — or browse all 836 templates.