Therapy Intake Form
Welcome!
Name of Client
*
First Name
Last Name
Name of Person Completing this Form (if not the client)
First Name
Last Name
Email
*
example@example.com
Phone
*
Format: (000) 000-0000.
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Client's Date of Birth
*
-
Month
-
Day
Year
Date
Preferred Method of Contact
*
E-mail
Text
Phone Call
I am looking for....
*
A therapist for myself
Couples Therapy
Family Therapy
Therapy for one or more of my children
Trauma Informed Yoga
I prefer to meet
*
In person
Online
I'm flexible
Qualities I look for in a therapist include...
A sense of humor
Someone who listens without interruption
Someone who challenges me
Someone who is a good problem solver
Someone who provides structure
Someone who gives good feedback
Someone involved in the LGBTQ+ community
Someone who has a positive outlook
Someone who is nurturing
How did you hear about us?
*
I am a returning client
Someone who is a current Key Therapy client
Word of mouth
Google
A family member or friend
Another clinician at Key Therapy
School system
Social media
My PCP, APRN, or other Healthcare Provider
My insurance company
If you were referred by your PCP, APRN or other Healthcare Provider what is their name?
*
Insurance Information
Name of Insurance (if none write N/A)
*
Member ID
*
Medical History
Do you have a history of substance abuse or addiction?
*
No
Yes
Are you currently taking prescription medication?
*
No
Yes
Prescribing Doctor's Name
First Name
Last Name
Mental Health History
Tell us a little bit about yourself and what is bringing you to treatment so we can match you with the right fit.
*
Days/times you are available
*
Have you seen a counselor, psychologist, psychiatrist or other mental health professional before?
*
Yes
No
Are you a veteran or an active member of the military?
*
Do you have a history within the last 6 months of suicide attempt?
*
Do you have a history within the last 6 months of self-harm?
*
Are you currently involved in any legal disputes?
*
Are you currently in a household that is experiencing domestic violence?
*
*Domestic Violence requires special care and expertise. Please let us know if you are currently in a situation where you are experiencing DV or if you are at risk of DV so we can help you find the proper services.
Client's Under 18
Is the Client under the age of 18?
*
Yes
No
If Yes, what is the caregiving status?
*
Two Parent Household/Married
Ongoing Divorce/Separation
Divorced with Joint Custody
Divorced with one parent having Full Custody
N/A
If there is shared custody of the client, please provide information for the other legal guardian:
First Name
Last Name
Email
Phone Number
Format: (000) 000-0000.
Is there a history of DCF involvement?
Does your child have in IEP or 504 plan?
Additional comments or concerns
Submit
Should be Empty: