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.
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.
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?*

YesNo
If yes, please provide a brief history:
Are you currently taking any medications?*

YesNo
If yes, please list:
Do you have any medical conditions or allergies?*

YesNo
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?*

YesNo
If yes, please list and provide brief details:
Have you ever attempted or considered self-harm or suicide?*

YesNo
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*

Powered by Jotform SignClear
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.