What to Include on a Counseling Intake Form

What to Include on a Counseling Intake Form

Whether you’re just opening a new private practice or you’ve been in business for years, having an effective counseling intake form is a major piece of the health of your practice. In this post, we are going to dissect what you should include in your counseling intake form, as well as provide you with a FREE editable counseling intake form pdf template you can use.

What is a Counseling Intake Form?

A counseling intake form is a tool used by mental health professionals by you to collect valuable information to effectively treat your patients. A counseling intake form is extremely valuable to the practitioner for several reasons:

  • It provides documented answers to important questions
  • It highlights your patient’s history with therapy and other practitioners
  • It showcases a patient’s treatment history
  • It shows a patient’s goals for therapy
  • It documents preferred payment methods
  • It highlights the therapeutic relationship

Download Our Free Counseling Intake Form PDF

If you’re looking for an intake evaluation counseling form example, you can download our free editable counseling intake form PDF below.

counseling-intake-form-pdf---free

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Download one of our other counseling practice forms

Would you like to take it to the next level? You can use our template with an electronic signature company to send digitally and request signatures from your patients.

Questions to Ask on a Counseling Intake Form

In our view, it is better to ask more questions than less questions when it comes to your counseling intake form. In this section, we will review a robust review of questions you could include on your intake form.

Patient Info

Here are some fields you could include in your patient info section:

  1. Date of birth
  2. Legal Name
  3. Preferred Name
  4. Preferred Gender Pronouns
  5. Gender
  6. Address
  7. City
  8. Zip
  9. Email
  10. Home Phone #
  11. Cell Phone #
  12. Work Phone #
  13. Other Phone #
  14. Which phone number can we leave a confidential message

Employer & Status

Here are some fields you could include in your employer and status section:

  1. Occupation
  2. Industry
  3. Company name
  4. Company address
  5. Company City
  6. Company Zip
  7. Employment type (self-employed, unemployed, retired, etc.)

Emergency contact counseling intake form

Emergency Contact Info

Here are a few fields you can include in your emergency contact info section:

  1. Emergency Contact Name
  2. Emergency Contact Phone #
  3. Relationship to Patient

Health and Medical Info

  1. Primary Care Physician
  2. Primary Care Physician Phone #
  3. Psychiatrist
  4. Psychiatrist Phone #
  5. Please List Any Medical Problems
  6. Please List Any Medications

Availability

In this section, you can create an availability question or chart asking which timeframe works best for your patient. Include:

  1. Days of the week
  2. Times in increments of 1 hour

Other Important Questions

Here are some other important questions you can include:

  1. Occupation
  2. Ethnicity
  3. Marriage status
  4. # of Persons in your Household
  5. Income Level
  6. Education Level Completed

Symptom Assessment

In the symptom assessment section of your counseling intake form, you could include a list of things including:

  1. “I am experiencing” with a list of items, level of frequency, and the length of time
  2. “I am feeling” with a list of items, level of frequency, and the length of time
  3. “I notice that I” with a list of items, level of frequency, and the length of time
  4. “I have” with a list of items, level of frequency, and the length of time
  5. “I use the following” with a list of items, level of frequency, and the length of time
  6. “My eating involves” with a list of items, level of frequency, and the length of time
  7. “Employment questions” with a list of items, level of frequency, and the length of time

Personal and Family History

In the personal and family history section of your counseling intake form, you could include questions like the following:

  1. Have you ever been hospitalized for a psychiatric illness?
  2. Has a family member ever been hospitalized for a psychiatric illness?
  3. Does anyone in your family have a history of mental illness?
  4. Have you ever attempted suicide?
  5. Has anyone in your family attempted or committed suicide?
  6. Do you have substance abuse problems?
  7. Does anyone in your family have substance abuse problems?
  8. Have you ever been arrested? Please explain.
  9. How well are you doing at your job? (scaled checkbox)
  10. How well are you doing in your marital or with your significant other (scaled checkbox)
  11. How well are you doing with family relationships? (scaled checkbox)
  12. How well are you doing in relationships with non-family members? (scaled checkbox)
  13. How is your current health? (scaled checkbox)
  14. How is your general happiness and well-being? (scaled checkbox)

Consent for Treatment

In this section of your counseling intake form, you should include legal consent for treatment which highlight appointment length, cost, and fee structure. This should also include confidentiality guidelines between you and your patient. Here are some subsections you could include in this section:

  1. Fees and Appointments
  2. Confidentiality
  3. Training and Clinical Supervision
  4. Counselor Availability
  5. Childcare Release
  6. Additional Rights and Responsibilities
  7. There should also be a place for your patient to date, print and sign their name

Consent to Use or Disclose Health Information

In this section of your counseling intake form, you should include:

  1. Patient’s name
  2. Patient’s Address
  3. Patient’s Phone Number
  4. Overview of consent to use or disclose health information for treatment, payment, and health care operations
  5. Acknowledgement of consent and understanding
  6. Patient name, signature, and date
  7. Representative of patient’s name, signature, and date (if necessary)

counselor telemedicine consent form

Consent for Telecounseling Services

In this section of your counseling intake form, you could include the following:

  1. Overview of telecounseling
  2. Requirements to sufficiently provide telecounseling
  3. Rights of the patient
  4. Responsibilities of the patient
  5. Patient consent including name, date, date of birth, and signature

Financial Agreement

Another important section to include in your counseling intake form is a financial agreement. This could include:

  1. Client Name
  2. Home Address
  3. Phone Number
  4. Email Address
  5. Number of Dependents
  6. Income Questions
  7. Expense Questions
  8. Patient Signature and date
  9. Costs associated with your services
  10. Ask for proof of income, include types acceptable

Intake Process in Counseling

After a patient completes the intake form, it is common to have an intake session. Here is a sample format you can use for your intake process session:

  1. Show empathy early on
  2. Review the intake form with your patient
  3. Review payment policy
  4. Describe your process to your patient
  5. Ask your patient about their therapy goals
  6. Listen and ask questions

Creating a Counseling Intake Form

When it comes to obtaining a counseling intake form, you can either create your own or use a templated counseling intake form. While creating a custom intake form may sound like a good idea, it can be costly and also you may miss out on important questions to include. Our template allows your patient to fill out the form on their computer and submit it to you. This can be invaluable to your practice as handwriting varies from legible to illegible.

Counselor intake form security

Making Sure Your Counseling Intake Form is Secure

Asking patients to fill out forms in person can be a laborious and time consuming process. It can be very beneficial to get your potential patients to fill out your counseling intake form ahead of time via electronic transmission. It’s important that you securely send forms to your patient. There are numerous companies you can use to send forms requiring signatures that are HIPAA compliant.

With our template, you can upload our document to a company like Docusign or other similar program (some customer relationship management companies allow this feature also) to set up for virtual sending use.

Final Thoughts on Your Counseling Intake Form

Thank you for reading our blog on what to include on your counseling intake form, we hope it was of incredible value to your practice. Your intake form is crucial to the health of your private practice. Being able to efficiently send and effectively store all of your intake forms securely will help your private practice operate in a way that will set you up for many years of success.

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Download one of our other counseling practice forms

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