New Client Intake Form (Counselling Therapy)

New Client Intake Form

Counselling Therapy
Personal Information
Client Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth

MonthDayYear
Date
Gender
Ethnicity
Marital Status
Email
example@example.com
Employment
Home Phone
Format: (000) 000-0000.
Cell Phone
Format: (000) 000-0000.
E-mailHome PhoneCell Phone
Who do you live with?
Health-care professionalFriend/familySocial MediaOther
EnglishArabicBoth
Billing Information

For therapy sessions
YesNo
MSI onlyIFHPThird-partyOther
Reasons for Seeking Help
What are the reasons for your visit today?
0 (not at all)12345678910 (completely can't function)
0 (not at all)12345678910 (completely can't function)
Average hours of sleep per night
Medical History
Name of your Family Doctor:
Please write N/A if you have none
NoneAllergiesAnemiaAnginaAnxietyArthritisAsthmaAtrial FibrillationBenign ProstaticHypertrophyBlood ClotsCancerCerebrovascular AccidentCronary Artery DiseaseCOPD (Emphysema)Crohn's DiseaseDepressionDiabetesGallbladder DiseaseGERD (Reflux)Hepatitis CHyperlipidemiaHypertensionIrritable Bowel DiseaseLiver DiseaseMigraine HeadachesMyocardial InfarctionOsteoarthritisOsteoporosisPeptic Ulcer DiseaseRenal DiseaseSeizure DisorderThyroid DiseaseOther
YesNo
NoDailyWeeklyLessFormer User
NoDailyWeeklyLessFormer User
NoDailyWeeklyLessFormer User
AdoptedAlcoholismAllergiesAsthmaArthritisBlood DiseaseCAD (Heart Attack)CancerCVA (Stroke)DepressionDevelopmental DelayDiabetesEczemaHearing DeficiencyHyperlipidemia (High Cholesterol)Hypertension (High Blood Pressure)Irritable Bowel DiseaseLearning DisabilityMental IllnessTuberculosisObesityOsteoarthritisOsteoporosisPVDRenal DiseaseOther
Mental Health History
YesNo
Therapist Name

First NameLast Name
Therapist Location
if applicable
YesNo
Please specify diagnoses, if any
HomeRelativeJobOther
YesNo
Therapy Goals
What motivated you to come here today?
What are your goals for counselling?
Additional comments or concerns
*Your signature below indicates that the information you have provided above is truthful.
**All information shared in this intake form follow the confidentiality agreement terms.
Date

MonthDayYear
Date
Signature
Should be Empty:

New Client Intake Form

Personal Information

Billing Information

Reasons for Seeking Help

Medical History

Mental Health History

Therapy Goals