Therapy intake form template for counselors and therapists

What a therapy intake form covers

Most counseling practices split intake into three parts:

1. Client information: contact details, emergency contact, insurance or self-pay.
2. Clinical intake: what brings the client in and the history the clinician needs before session one.
3. Consents and policies: informed consent to therapy, telehealth consent, fees and cancellations, communication preferences, and acknowledgment of the privacy notice.

Keep the clinical part short. Much of it is better explored in the first session than in a checkbox list, and every written answer becomes part of the record.

Client information and emergency contacts

• Legal name and the name the client wants you to use; pronouns (optional)
• Date of birth, address, mobile phone, email
• Safe contact preferences: may we call, text, email or leave a voicemail at each number?
• Emergency contact: name, relationship, phone, and a note that this person is contacted only in an emergency
• Insurance details, or self-pay

The contact-preference questions matter more in therapy than almost anywhere else. A voicemail from a counseling practice on a shared phone can reveal treatment, so ask before you call.

Presenting concerns and history (clinically reviewed)

This section must be written or approved by a licensed clinician at your practice. We don't supply clinical questions, screening tools or risk-assessment wording. Typical headings your clinician may fill:

• What brings you to therapy now, in your own words
• Previous counseling or psychiatric care (yes/no, with dates if relevant)
• Current medications and prescribing provider
• Primary care provider, and permission to coordinate care (a separate authorization where required)
• Any questions the clinician uses before the first session

If your practice uses standardized screening instruments, follow the instrument's own licensing and scoring instructions, and decide in advance who reviews responses and how quickly.

Informed consent, telehealth consent and practice policies

Each profession's ethics code sets out what informed consent must cover. Verify against your own code:

• Counselors. The 2014 ACA Code of Ethics (opens in a new tab), which the ACA says remains current (opens in a new tab) while a revision is in progress, requires counselors "to review in writing and verbally with clients the rights and responsibilities of both counselors and clients" (A.2.a). A.2.b lists topics including purposes, goals, techniques, risks and benefits, the counselor's credentials, the role of technology, fees and billing.
• Psychologists. APA Standard 10.01(a) (opens in a new tab) requires informing clients "as early as is feasible in the therapeutic relationship about the nature and anticipated course of therapy, fees, involvement of third parties, and limits of confidentiality."
• Social workers. NASW Code 1.03(a) (opens in a new tab) covers the purpose of services, risks, limits imposed by third-party payers, costs, reasonable alternatives, the right to refuse or withdraw consent, and the time frame covered.
• Marriage and family therapists. Check the informed-consent standard in the AAMFT Code of Ethics.

Telehealth consent. ACA standard H.2.a lists issues unique to distance counseling, including the counselor's credentials and physical location, risks and benefits, what happens if technology fails, anticipated response time, emergency procedures when the counselor isn't available, time zone differences and possible denial of insurance benefits. Telehealth rules also vary by state, so check your state licensing board before finalizing this section.

Practice policies. Fees, cancellation and late policy, how to reach you between sessions, and what to do in a crisis outside office hours.

Minors and guardians: consent sections to verify by state

HIPAA defers to state law here. A parent or guardian is generally the minor's personal representative when "under applicable law" they have authority to make the minor's health care decisions, but not when the minor can lawfully consent to the service, a court authorizes it, or the parent agrees to a confidentiality arrangement (45 CFR 164.502(g)(3) (opens in a new tab)).

Ages and services that allow a minor to consent to mental health care differ by state. Build the template with a guardian section and a note on custody documents, then have your attorney or state licensing board guidance decide when it's required. We don't state any state's rules here.

Privacy: HIPAA, psychotherapy notes and substance use records

Psychotherapy notes get extra protection. HIPAA defines them as notes "documenting or analyzing the contents of conversation during a private counseling session" that "are separated from the rest of the individual's medical record" (45 CFR 164.501 (opens in a new tab)). Medication monitoring, session times, diagnosis, treatment plan and progress summaries are excluded from the definition. With limited exceptions, "a covered entity must obtain an authorization for any use or disclosure of psychotherapy notes" (45 CFR 164.508(a)(2) (opens in a new tab)). Intake answers are part of the regular record, not psychotherapy notes.

Substance use disorder records. If your program is a "Part 2 program," meaning a federally assisted program that holds itself out as providing substance use disorder diagnosis, treatment or referral (42 CFR 2.11 (opens in a new tab)), its records fall under 42 CFR Part 2. "Federally assisted" is broad: it includes participating in Medicare, holding a DEA registration to dispense controlled substances used for SUD treatment, receiving federal funds, or tax-exempt status (42 CFR 2.12 (opens in a new tab)).

The 2024 final rule (opens in a new tab) from HHS's Office for Civil Rights and SAMHSA, effective April 16, 2024 with a compliance date of February 16, 2026, aligned Part 2 more closely with HIPAA. It allows a single patient consent for all future uses and disclosures for treatment, payment and health care operations, with the specific elements set out in 42 CFR 2.31 (opens in a new tab). See 42 CFR Part 2 explained and HIPAA compliance for therapists for the full picture.

This is general information, not legal advice. Confirm how it applies to your practice with a qualified advisor.

Free therapy intake form template

Copy this into your intake tool or word processor. It is a starting point: a licensed clinician must write or approve the clinical section, and your attorney should review the consent language for your state.

Part 1: Client information

• Legal name; name you'd like us to use; pronouns (optional)
• Date of birth; address; mobile phone; email
• OK to call this number
• OK to text this number
• OK to leave a voicemail that mentions our practice
• OK to email (email may not be encrypted)
• Emergency contact: name, relationship, phone (contacted only in an emergency)
• Insurance: plan, member ID, subscriber; or [ ] self-pay

Part 2: Clinical intake (written or approved by your clinician)

• What brings you to therapy now?
• [Clinician-approved history questions]
• Current medications and prescriber
• Primary care provider

Part 3: Guardian information (minors; verify state rules)

• Guardian name(s), relationship, phone
• Legal custody arrangement and documents on file: yes / no

Part 4: Consents and policies

• I have read and agree to the informed consent to therapy, including fees and the limits of confidentiality
• I have read and agree to the telehealth consent (if applicable)
• I have read the cancellation and payment policy
• I received the Notice of Privacy Practices
• Signature; printed name; date; if signed by a guardian, relationship

Where Medfy fits. Medfy provides HIPAA-compliant website forms: submissions go to an access-controlled patient CRM and inbox, patient information is stored in separate, encrypted HIPAA databases in the US or Canada, and Medfy signs a BAA with each practice. Medfy does not offer e-signatures, insurance-card capture or full digital intake packets, so consents that need signatures belong in a dedicated intake tool that signs a BAA; compare online intake options. For the rest of intake, see our patient intake form templates; for growing the practice, see marketing for therapists or run a free marketing audit.

Frequently asked questions

What should a therapy intake form include?

Client contact details and an emergency contact, insurance or self-pay information, a short section on what brings the client in and any history the clinician needs before the first session, informed consent to therapy covering fees, confidentiality and its limits, telehealth consent if you offer video sessions, and practice policies such as cancellations. A licensed clinician should write or approve every clinical question.

Can therapy intake forms be completed online?

Yes, if the form tool and wherever submissions are stored sign a business associate agreement and protect the data with encryption, individual logins and audit logs. Keep advertising pixels and analytics off the form pages, since a therapy intake page reveals that someone is seeking mental health care. If you need e-signatures on consents, use a dedicated intake tool rather than a basic website form.

Do minors need a parent's consent on a therapy intake form?

It depends on the state and the service. HIPAA's rules anticipate that state law may let a minor consent to some care on their own, and they follow state law on whether a parent acts as the minor's personal representative. Build the form with a guardian section, but have your attorney or licensing board guidance decide when the guardian must sign and what they may see.