Therapy Intake Form

Therapy Intake Form

Welcome!
Name of Client*

First NameLast Name
Name of Person Completing this Form (if not the client)

First NameLast Name
Email*
example@example.com
Phone*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Client's Date of Birth*

MonthDayYear
Date
Preferred Method of Contact*

E-mailTextPhone Call
I am looking for....*

A therapist for myselfCouples TherapyFamily TherapyTherapy for one or more of my childrenTrauma Informed Yoga
I prefer to meet*

In personOnlineI'm flexible
Qualities I look for in a therapist include...

A sense of humorSomeone who listens without interruptionSomeone who challenges meSomeone who is a good problem solverSomeone who provides structureSomeone who gives good feedbackSomeone involved in the LGBTQ+ communitySomeone who has a positive outlookSomeone who is nurturing
How did you hear about us?*

I am a returning clientSomeone who is a current Key Therapy clientWord of mouthGoogleA family member or friendAnother clinician at Key TherapySchool systemSocial mediaMy PCP, APRN, or other Healthcare ProviderMy 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?*

NoYes
Are you currently taking prescription medication?*

NoYes
Prescribing Doctor's Name

First NameLast 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?*

YesNo
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?*

YesNo
If Yes, what is the caregiving status?

Two Parent Household/MarriedOngoing Divorce/SeparationDivorced with Joint CustodyDivorced with one parent having Full Custody
If there is shared custody of the client, please provide information for the other legal guardian:

First NameLast Name
Email
Phone Number
Is there a history of DCF involvement?
Does your child have in IEP or 504 plan?
Additional comments or concerns
Should be Empty:

Therapy Intake Form

Insurance Information

Medical History

Mental Health History

Client's Under 18