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Client Intake Form for Counseling

The Client Intake Form collects essential client information, including personal details, presenting concerns, medical and family history, and cultural considerations. It outlines confidentiality agreements and informed consent, ensuring clients understand the limits of confidentiality. The form also encourages customization to better serve diverse clientele and emphasizes the importance of maintaining client confidentiality.

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saniadhanda100
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94 views2 pages

Client Intake Form for Counseling

The Client Intake Form collects essential client information, including personal details, presenting concerns, medical and family history, and cultural considerations. It outlines confidentiality agreements and informed consent, ensuring clients understand the limits of confidentiality. The form also encourages customization to better serve diverse clientele and emphasizes the importance of maintaining client confidentiality.

Uploaded by

saniadhanda100
Copyright
© All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd

Client Intake Form

Client Information:

● Client Name:
● Date of Birth:
● Gender:
● Pronouns (optional):
● Contact Information (Phone, Email):
● Emergency Contact Information (Name, Phone Number):

Presenting Concerns:

● Briefly describe the reasons for seeking counselling/therapy (e.g., feeling anxious,
difficulty sleeping, relationship problems):

Medical History (if relevant):

● Do you have any current or past medical conditions (physical or mental health)?
(Yes/No)
● If yes, please specify:
● Are you currently taking any medications? (Yes/No)
● If yes, please list medications and dosages:
● Do you have any allergies? (Yes/No)
● If yes, please specify:

Family History (optional):

● Briefly describe your marital status, number of children (if any), and any relevant family
background information:

Social History (optional):

● Briefly describe your work/education, social life, and any other relevant background
information:

Cultural Considerations:

● Is there anything related to your cultural background that you feel is important for me to
know in regard to your mental health? (Optional)

Expectations from Therapy:

● What are your hopes for getting out of counselling/therapy?


Confidentiality:

● I understand that all information shared during counselling sessions will be kept
confidential, except in the following situations:
○ There is a reasonable suspicion of harm to yourself or others (e.g., suicidal
ideation, child abuse).
○ A court order requires disclosure of information.
○ You provide written consent for information to be shared with a third party (e.g.,
an insurance company, or another healthcare provider).

Informed Consent:

● I acknowledge that I have received and reviewed a copy of the Informed Consent Form
provided by [Therapist Name].

Client Signature:
Date:

Therapist Signature:
Date:

Additional Notes:

● You can further customize this form by including a section for preferred methods of
communication (phone, email, etc.) and preferred appointment times.
● Consider translating the form into additional languages if you serve a diverse clientele.

Remember:

● Maintain confidentiality of all client information.


● Store completed forms securely in client files.
● Update the form periodically to reflect any changes in your practice policies.

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