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Counselling / therapy intake form template

Confidential first-session intake for counsellors, therapists and psychologists.

14 questions · 3 pages · fully editable

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Page 1 · About you

Full name *

Preferred name and pronouns

Date of birth *

Email *

Phone *

Is it OK to leave a voicemail? * Yes
No

Page 2 · What brings you here

What would you like help with? *

Type of session * Individual
Couples
Family
Child / teen

Session format * In person
Video
Phone
No preference

Have you seen a counsellor before? Yes
No

Best times for sessions Weekday mornings
Weekday afternoons
Weekday evenings
Weekends

Page 3 · Consent

Emergency contact name and phone *

If you are in crisis or thinking about harming yourself, please call your local emergency number or crisis line right away. This form is not monitored around the clock.

I understand how my information is kept confidential and the limits of confidentiality. * I understand

Signature *

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Need a website too?

This form comes ready-made inside a full website — your own domain, phone buttons and all.

Riverbend CounsellingCounselling / therapy practice websiteA calm, private practice site with a confidential intake form.Preview the site →

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