Client Intake

Client Intake
Name

First NameLast Name
Phone Number
Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Time Zone
Date of Birth

MonthDayYear
Date
Email
example@example.com
Primary Emergency Contact
Emergency Contact

First NameLast Name
Phone Number
Format: (000) 000-0000.
State
Email
example@example.com
Secondary Emergency Contact
Name

First NameLast Name
Phone Number
Format: (000) 000-0000.
State
Email
example@example.com
Care Team
Primary Therapist

First NameLast Name
Type of Therapist
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
YesNo
Notes
Additional Therapist

First NameLast Name
Type of Therapist
Phone Number
Format: (000) 000-0000.
Email
example@example.com
YesNo
Notes
Attorney

First NameLast Name
Phone Number
Format: (000) 000-0000.
Email
example@example.com
YesNo
Spiritual Director/Counselor/Pastor/Etc.

First NameLast Name
Phone Number
Format: (000) 000-0000.
Type of Support
Email
example@example.com
YesNo
Life Coach

First NameLast Name
Phone Number
Format: (000) 000-0000.
Email
example@example.com
YesNo
Sponsor

First NameLast Name
Phone Number
Format: (000) 000-0000.
Email
example@example.com
YesNo
Reasons for Support
What brings you here now?
What feels most urgent or overwhelming at this moment?
Are there any safety concerns (physical or emotional) I should know about?
Domains of Stability & Disruption
Emotional healthMental clarity or decision makingPhysical wellness / nervous system regulationSpiritual groundingIdentity / sense of selfRelationships / social supportLegal issuesReputational issuesFinancial securityVocational or career disruptionRecovery or addiction related issuesOther
Self-reflection & Priorities
What are you hoping most to receive from this support?
Have you experienced a disruption similar to this one before? If yes, how is this different?
What are 1-2 things helping you stay afloat right now?
What do you already know helps calm or anchor you when things feel intense?
Logistics & Preferences
Tell me about your style of communication. Do you like space to just speak? Or do you like to be prompted with questions?
Are there any communication needs I should be made aware of?
Final Reflection
Any final thoughts I should be aware of before we begin?
Should be Empty:

Client Intake

Primary Emergency Contact

Secondary Emergency Contact

Care Team

Reasons for Support

Domains of Stability & Disruption

Self-reflection & Priorities

Logistics & Preferences

Final Reflection