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Private Practice Counseling Intake Form

Efficiently onboard new clients in your private practice with this comprehensive counseling intake form. Collect personal details, mental health history, and therapy goals to prepare for effective treatment. Ideal for solo practitioners, therapists, and small counseling practices.

3 minutes to complete

Eligibility

To be eligible to complete the Private Practice Counseling Intake Form, individuals must be over the age of 18, seeking counseling services for themselves or a minor child in their care, and able to provide accurate and honest information about their mental health history, current concerns, and goals for therapy.

Questions for Private Practice Counseling Intake Form

Questions

1.

Full Name

The answer should be a text input.
2.

Date of Birth

The answer should be a date input.
3.

Contact Information

The answer should be a phone number.
4.

Emergency Contact Phone

5.

Referral Source

The answer should be a single choice:
  1. Friend or family member
  2. Social media
  3. Online advertisement
  4. Search engine
  5. Company website
  6. Email newsletter
  7. Trade show or event
  8. Word of mouth
6.

Presenting Concern

The answer should be a text input.
7.

Current Symptoms or Issues

The answer should be a text input.
8.

Medical and Mental Health History

The answer should be a text input.
9.

Previous Counseling or Psychiatric Treatment

The answer should be a text input.
10.

Substance Use History

The answer should be a text input.
11.

Goals for Counseling

The answer should be a text input.
12.

Consent Acknowledgement

The answer should be a single choice:
  1. I acknowledge and agree to the terms and conditions.
  2. I have read and understood the consent information provided.
  3. I consent to proceed with the understanding of the terms outlined.
  4. I do not consent to the terms and wish to withdraw.
13.

Insurance Information

The answer should be a text input.

Forms Similar to Private Practice Counseling Intake Form

  • Mental Health Assessment Form
  • Therapy Intake Questionnaire
  • Client Information Form
  • Treatment Consent Form
  • Counseling Services Agreement
  • Intake Evaluation Form

Here are some FAQs and additional information
on Private Practice Counseling Intake Form

Why is an intake form important in a private practice setting?

It helps therapists understand a client’s background, mental health history, and goals before the first session—making therapy more focused and efficient from the start.

Is my information secure and confidential?

Yes. All data collected is securely stored and protected according to HIPAA and professional ethical standards. Only your therapist will have access to it.

Can this form be customized for my private practice needs?

Absolutely. You can tailor the form to match your therapy style, specialties, or client types (e.g., adults, couples, children).

Do clients need to fill this form out for every session?

No. The intake form is typically filled out once before the initial session. Updates may be requested if the client’s circumstances or health status changes.

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