Client Intake Form
Name
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Would you prefer your therapy session to be -
Face to Face sessions
Zoom
Phone
Preferred methods of contact
Email
Phone call
Text
All of the above
Briefly describe your family background and history
What motivated you to seek therapy right now?
What are your goals in these sessions?
What do you hope to achieve / change through therapy?
How would you rate your emotional. mental well - being? (1 low - 10 high)
1
2
3
4
5
6
7
8
9
10
Describe your current support system? (Family, friends, community groups)
How do you generally manage stress or emotional discomfort?
Do you have any concerns or questions about the process?
Signature
Submit
Should be Empty: