Individual Therapy Intake Form

Individual Therapy Intake Form
I appreciate your interest in individual therapy. This form helps us understand your needs and schedule your sessions accordingly. Please complete the information below with as much detail as possible.
INSURANCE & PAYMENT OPTIONS
Insurance Type: (Please select one from the dropdown menu)
If you choose this option, you agree to pre-purchase five consecutive sessions with one reschedule session allowed out of the five. There are no refunds, even if you do not complete your sessions.
SESSION PREFERENCES

60-minute session 45-minute sessionPlease select your preferred session length:
ABOUT INDIVIDUAL THERAPY
Individual therapy provides a one-on-one setting with askilled therapist who offers a caring and supportive space forpersonal growth and healing. Sessions may be conducted viaZoom or in person based on your preference. Our goal is tosupport you in navigating life’s challenges with clarity andconfidence
Mode of Therapy

Zoom (Virtual)In-Person
CLIENT INFORMATION
Full Name:
Phone Number:
Date of Birth

MonthDayYear
Date
Email
SCHEDULING PREFERENCES
Please provide the day(s) of the week you are interested in and possible time slots. The requested time is not guaranteed.
Preferred Time (s)
Day of the week
THERAPEUTIC GOALS
What brings you into therapy?
What is your motivation for therapy?
CONSENT & AGREEMENT
I acknowledge that all information provided is accurate to the best of my knowledge. If selecting the Promotion option, I understand that the purchase is non-refundable, even if I do not complete all sessions
Signature: Date

Clear
FOR OFFICE USE ONLY
I acknowledge that all information provided is accurate

to the best of my knowledge.
Assigned Therapist
Session Start Date

MonthDayYear
Date
Additional Notes
Signature: Date

MonthDayYear
Date
Thank you for completing this form. We look forward to supporting you on your journey to healing and growth!
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Individual Therapy Intake Form

INSURANCE & PAYMENT OPTIONS

ABOUT INDIVIDUAL THERAPY

CLIENT INFORMATION

SCHEDULING PREFERENCES

THERAPEUTIC GOALS

CONSENT & AGREEMENT

FOR OFFICE USE ONLY