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....
*
Individual Therapy
Couples Therapy
Family Therapy
Therapy for my child
I prefer to meet
*
In person
Online
I'm flexible
Days/times you are available
*
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
*
Mental Health History
These questions are designed to help us better understand your mental health history and current needs so we can determine the best fit for your care. If we’re unable to provide the support you need, this information will help us offer appropriate referrals and recommendations.
Tell us a little bit about yourself and what is bringing you to treatment so we can match you with the right fit.
*
Do you have a history or current thoughts of Suicide or Self Harm?
*
No, There is no history of suicide thoughts, attempts or self harm
Yes, I have had Past suicide attempts or thoughts
Yes, I have Current suicide thoughts
Yes, I have self harmed in the past
Yes, I currently self-harm
Do you have a current or past history of substance abuse?
*
No, There is no history of substance abuse
Yes, I am currently using substances
Yes, I have a history of substance abuse
Are you currently experiencing or do you have a history of domestic violence?
*
No, There is no history of domestic violence
Yes, There is a history of domestic violence
Yes, I am currently experiencing domestic violence
Have you had any current or past arrests, court involvement, or DCF involvement ?
*
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 and Last Name
Email
Phone Number
Additional comments or concerns
Submit
Should be Empty: