Intake and Consent Form

Intake and Consent Form

Please complete the intake, consent, clinical history, family history, and video consent information based on the source PDF. Preserve the original wording where possible.
Intake and Contact Information
Date

MonthDayYear
Date
Name of client 1
Date of birth

MonthDayYear
Date
Full Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Telephone
Please enter a valid phone number.Format: (000) 000-0000.
Gender
Pronouns
Marital Status
Race / Ethnicity

Other
Email 1
example@example.com
Email 2
example@example.com
Emergency Contact Name
Emergency Contact Telephone
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contact Relationship
Insurance Member ID
Insurance Company
Fee / Copay
Therapeutic Agreement and Treatment Authorization

Refer to informed consent link
Agreement to therapeutic agreement - Date

MonthDayYear
Date
Treatment Authorization - Client/Parent Name

First NameLast Name
Treatment Authorization - Who is being treated?
Agreement to therapeutic agreement - Signature
Treatment Authorization - Date

MonthDayYear
Date
Client Intake and Communication Preferences
Client Intake - Name

First NameMiddle NameLast Name
Client Intake - Date

MonthDayYear
Date
Parent / Legal Guardian (if under 18)
DOB

MonthDayYear
Date
Age
Referred By
Clinical History and Current Symptoms
Previously received mental health services?
Previous therapist / practitioner
Currently taking prescription medication?
Current prescription medications
Ever prescribed psychiatric medication?
Psychiatric medications and dates
Current physical health rating
Current specific health problems
Current sleeping habits rating
Current specific sleep problems
Times per week you exercise
Types of exercise
Appetite or eating problems
Currently experiencing overwhelming sadness, grief or depression?
If yes, for approximately how long?
Currently experiencing anxiety, panic attacks or phobias?
If yes, when did you begin experiencing this?
Currently experiencing any chronic pain?
If yes, please describe chronic pain
Drink alcohol more than once a week?
Frequency of recreational drug use
Currently in a romantic relationship?
If yes, for how long?
Relationship rating

1

2

3

4

5

6

7

8

9

10

1 is Poor, 10 is Excellent
Recent significant life changes or stressful events
Family History and Psychosocial History
Family history - Alcohol / Substance Abuse
Family member with Alcohol / Substance Abuse
Family history - Mental Health Issues
Family member with Mental Health Issues
Family history - Suicide Attempts
Family member with Suicide Attempts
Family history - Domestic Violence
Other psychosocial concerns
What are you goals for therapy? What are you looking for in a therapist?
Video Consent/ Use of AI notetaker
I consent to participate in video sessions or AI notetaking for my therapy appointments.
I understand that video sessions may involve risks to privacy and confidentiality.
I understand that I am responsible for choosing a private location for my video sessions.
I understand that technical problems may interrupt or delay video sessions.
Client Signature
Name

First NameLast Name
Date

MonthDayYear
Date
Should be Empty:

Intake and Consent Form

Intake and Contact Information

Therapeutic Agreement and Treatment Authorization

Client Intake and Communication Preferences

Clinical History and Current Symptoms

Family History and Psychosocial History

Video Consent/ Use of AI notetaker