Psychotherapy Intake Form

Psycotherapy Intake Form

To better assist you please take your time to fill out our intake form
Personal Information
Name

First NameLast Name
Preferred Name
Gender
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth

MonthDayYear
Date
Emergency Contact
Emergency Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Referral Information
How did you hear about our practice?
Name of Referring Provider (if applicable):
Reason for Seeking Therapy:
Briefly describe your current concern or challenge:
Background Information:
Have you received therapy or counseling before?
If yes, please provide a brief history:
Are you currently taking any medications?
If yes, please list:
Do you have any medical conditions or allergies?
If yes, please describe:
Please list any relevant past or current medical treatments:
Psychological History:
Have you ever been diagnosed with a mental health disorder?
If yes, please list and provide brief details:
Have you ever attempted or considered self-harm or suicide?
If yes, please provide additional information:
Personal History:
Please provide a brief overview of your family and upbringing:
Are there any significant life events or traumas you'd like to share?
What are your current living and social circumstances like?
Therapy Goals:
What are your primary goals for therapy?
What do you hope to achieve through this therapeutic process?
Preferences and Accessibility:
Do you have any preferences for the therapist's gender, age, or cultural background?
Do you have any accessibility needs or preferences for the therapy format (in-person, online, phone, etc.)?
Additional Information:
Is there anything else you would like your therapist to know or consider?
Consent and Agreement:
I have read and understand the information provided on this intake form. I hereby consent to engage in psychotherapy services with Health & Light Institute. I understand that the information shared during sessions will be kept confidential except in cases where there is a risk of harm to myself or others, as required by law. I agree to attend sessions as scheduled and to participate actively in the therapeutic process.
Signature
Date

MonthDayYear
Date
Once you've completed the form, please click Submit.

We look forward to serving you!
Should be Empty:

Psycotherapy Intake Form

Personal Information

Referral Information

Background Information:

Psychological History:

Personal History:

Therapy Goals:

Preferences and Accessibility:

Additional Information:

Consent and Agreement:

Once you've completed the form, please click Submit.