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Client Intake Form Brief

The document is an intake interview form for clients seeking therapy, collecting essential personal information, presenting concerns, mental health history, and confidentiality agreements. It outlines the therapy contract, including session details and client participation expectations. Additionally, it allows clients to set therapy goals and specify their preferred therapeutic approach.

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nhlmhd7
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5 views2 pages

Client Intake Form Brief

The document is an intake interview form for clients seeking therapy, collecting essential personal information, presenting concerns, mental health history, and confidentiality agreements. It outlines the therapy contract, including session details and client participation expectations. Additionally, it allows clients to set therapy goals and specify their preferred therapeutic approach.

Uploaded by

nhlmhd7
Copyright
© All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd

Intake Interview Form

Section 1: Client Information


Full Name: ______________________________
Date of Birth: ___________________________
Gender: _________________________________
Phone Number: ___________________________
Email Address: __________________________
Emergency Contact: ______________________
Relationship to Client: _________________
Emergency Contact Phone: ________________

Section 2: Presenting Concerns


1. What brings you to therapy today?
________________________________________________________
________________________________________________________
2. How long have you been experiencing these concerns?
________________________________________________________
3. Have you previously received psychological or psychiatric treatment?
________________________________________________________

Section 3: Mental Health History


1. Previous psychological/psychiatric treatment?
____________________________________________________________
2. Current medications?
____________________________________________________________
3. Recent major stress or life events?
____________________________________________________________

Section 5: Confidentiality

Information shared in therapy is confidential except in these situations:


 Risk of harm to yourself
 Risk of harm to others
 Legal requirements or court orders
 Cases involving abuse or neglect

Client Name: __________________________


Signature: ____________________________
Date: _________________________________

Therapist Name: ___________________________


Signature: _________________________________
Section 5: Therapy Contract Agreement

 Sessions last approximately 1 hour.


 Clients are encouraged to attend sessions regularly.
 Inform the therapist if you need to cancel or reschedule.
 Therapy progress requires active participation.

Client Signature: ______________________

Date: _________________________________

Section 6: Therapy Goals & Psychotherapy Treatment Plan

What changes would you like to see as a result of therapy?


________________________________________________________
________________________________________________________

Primary Concerns: _____________________

Therapy Goals
Goal: __________________________________________
Goal: __________________________________________
Goal: __________________________________________

Therapeutic Approach
CBT / ACT / DBT / MI / REBT / Other: __________________
Next Review Date: _________________________________

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