3 minutes to complete
To complete the Psychotherapy Intake Form, individuals must be at least 18 years old, have a desire to engage in therapy, and be willing to provide honest and accurate information about their mental health history, current concerns, and goals for therapy.
Patient Details
Briefly describe the main concern(s) that bring you to therapy:
When did these concerns begin?
Are you currently taking any medication(s)? If yes, please list:
Have you previously received counseling or mental health treatment?
Do you have any current health conditions or significant medical history?
How would you rate your current mood?
Are you experiencing difficulties with (check any that apply):
What do you hope to achieve through therapy?
Is there anything you would like your therapist to know about you or your background?
Are there any preferences or concerns regarding the therapy process?
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Creating surveys with BlockSurvey has been a breeze. The drag-and-drop interface is intuitive, and we’re able to collect data anonymously and securely—without intermediaries. It’s interactive, friendly, and encourages high participation while protecting user privacy. The reports are solid, and we’ve used it confidently for internal and external feedback.
Few tools combine data confidentiality and form aesthetics like this one. The conversational design improved my response rate by 43%, and the webhook integrations made syncing to our CRM effortless. I also love how responsive and community-driven the support team is.
I think BlockSurvey is good for short and long surveys. What I find the best is the fact that there are so many templates I can use and customize.
