Psychotherapy Form

Psychotherapy Intake Form for new clients

This information is held in strict confidence, please fill in as much information as you can.
Intake & Consent Form
Name*

First NameLast Name
Date of birth:

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Email*
example@example.com
Ages of children under age of 18 (if applicable)
Occupation
Emergency Contact Name*
Emergency Contact Number*

Health information
Are you taking any medications for your mental health? If yes, please specify.
Do you have any long term health conditions? If yes, please specify.
Do you smoke?

YesNo
How many per day?
Do you drink alcohol?

YesNo
How many times per week?
Do you take recreational drugs?

YesNo
How frequently?
Please describe what your sleep is like. (i.e. how many hours of sleep do you get, do you struggle to get to sleep or stay asleep).
How do you unwind or relax, or coping strategies/ hobbies that you find help?

Assessment information
What brings you to inquire about therapeutic support (include here any relevant presenting information or symptoms that you are experiencing, e.g. feeling anxious, down, stressed...)*
How long have these symptoms been present: is this the first experience? If not, when have you experienced this in the past and were there stressors/factors contributing at that time?*
What are your goals/intentions/areas of focus for therapy?*
Have you had therapy before? If yes, please give some further information (what type of therapy it was, when you had it, how long for, and how you responded to it- was it helpful/unhelpful?)*
What are you looking for in a therapist?
Where did you hear about me? (Google, social media, word of mouth, Psychology Today etc.)*

Data Protection/ GDPR

GDPR statement:
Your personal data is stored securely and will only be used for the purpose of communication, scheduling, and safety. You have the right to request access, correction, or deletion of your data at any time.
I consent to my data being stored and processed in line with GDPR:*

I consent
Signature*

Powered by Jotform SignClear
Date*

MonthDayYear
Date
Should be Empty:

Psychotherapy Intake Form for new clients