Client Intake Form
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
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
Availability / Preferred appointment days & times
Monday 9 - 12 pm
Monday 12 - 8 pm
Tuesday 9 - 12pm
Tuesday 12 - 8 pm
Wednesday 9 - 12 pm
Wednesday 12 - 8 pm
Thursday 9 - 12 pm
Thursday 12 - 8 pm
Friday 9 - 12 pm
Friday 12 - 8 pm
Saturday 10 - 12 pm
Saturday 12 - 3 pm
How did you hear of my services
*
Friend/Colleague
Psychology Today
Good Therapy
Google/Instagram/Facebook
Other
Have you had therapy before? If yes, what was the experience like?
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 address or 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?
*
If there was one thing you feel I need to know about you what would it?
*
Do you have any concerns or questions about the process?
*
Signature
Submit
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