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🧠 Intake Form Template

Therapy & Counseling Intake Form Template

Confidential intake form for therapists and counselors — collect mental health history, current symptoms, stress levels, and therapy goals. An online questionnaire with 10 customizable fields.

10 Fields
~4 min
Free
Confidential
Live Preview
Sample Form Fields
Full Name name
Date of Birth input
Phone Number phone
Reason for Seeking Counseling long-text
Previous Therapy Experience radio
Current Stress Level number
Experiencing Symptoms checkbox
Support System long-text
10 fields total · ~4 min to complete

Quick answer

Free therapy intake form template for counselors. Collect mental health history, symptoms, and goals with 10 fields — confidential.

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Live Preview

This is the actual running form — not a screenshot. Try it yourself.

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This is the actual therapy intake form your clients will see. All responses are strictly confidential.
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Who Is This For

Pick your role — see how the form fits your workflow.

1

Private Practice Therapists

Prepare for sessions with full client context. Workflow: Client completes intake → Review symptoms & history → Plan first session → Provide informed, personalized care.

2

Counseling Centers

Standardize intake across your team. Workflow: Client fills form online → Route to appropriate counselor → Review before session → Track client progress over time.

3

Telehealth Therapists

Collect intake information before virtual sessions. Workflow: Send digital form → Client completes remotely → Review prior to video call → Start session prepared.

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Sample Questions Inside

A preview of real questions from this template — the full version adds scoring logic, branching and a personalized report per respondent.

  1. What brings you in? (multi-select)
  2. Prior therapy or counseling? (yes / no + text)
  3. Preferred approach (CBT, talk, EMDR…) (choice)
  4. Availability for sessions (checkbox)
  5. Insurance or self-pay (choice)
  6. Any safety history we should know about? (prefer to disclose / no)
  7. What would a good outcome look like for you? (text)
  8. Consent policies acknowledged (checkbox)
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Frequently Asked Questions

What is a therapy intake form?
A therapy intake form is a confidential questionnaire used by counselors and therapists to collect a client's mental health background, current symptoms, and therapy goals before the first session.
Is this therapy intake form template free?
Yes. Click "Use This Template" to copy the full form into your FormLM workspace for free. No credit card required.
Is the information kept confidential?
Yes. All submissions are encrypted and handled with strict confidentiality. The form includes a confidentiality notice for clients.
What fields should a therapy intake form include?
A therapy intake form should include: full name, date of birth, phone, reason for seeking counseling, previous therapy experience, current stress level, experiencing symptoms, current medications, support system, and therapy goals.
Can I customize this for different therapy approaches?
Yes. After copying, add CBT-specific questions, trauma screening fields, or couples therapy fields depending on your practice.

Start Every Session with Full Client Insight

Copy the Therapy Intake Form into your workspace, customize it, and share it with clients. Free to start.