New Client Intake Form

Personal Information

First Name

Last Name

Date of Birth

Gender

Home Address

City

State

Phone Number

Email Address

Preferred Method of Contact

Emergency Contact Name & Phone

Example: John Doe, +234 800 123 4567 (Relationship: Spouse)

Reason for Seeking Therapy

What are your primary concerns or reasons for seeking therapy?

How long have you been experiencing these concerns?

What are your goals for therapy? What would you like to achieve?

Mental Health History

Have you ever received therapy or counseling before?

Yes No

If yes, please provide details (when, for how long, type of therapy, was it helpful):

Are you currently taking any medications for mental health?

Yes No

If yes, please list current medications and dosages:

Have you ever been hospitalized for mental health reasons?

Yes No

If yes, please provide details:

Have you ever had thoughts of harming yourself or others?

Yes No

Please describe any family history of mental health issues:

Medical & General Information

Please list any current medical conditions:

Primary Care Physician (Name and Contact):

Are you currently working?

Full-time Part-time Unemployed Student Retired

Current occupation (if applicable):

Relationship Status:

Single Married Domestic Partnership Separated Divorced Widowed

Do you have children? If yes, please list their ages:

Therapy Preferences

Preferred Therapy Format:

In-person Video Sessions Phone Sessions Flexible (mix of formats)

Preferred Session Frequency:

Weekly Every other week Monthly As needed

Therapist Gender Preference:

Female Male No preference

Please indicate days/times you are generally available for sessions:

Example: Mondays after 5pm, Tuesday mornings, etc.

Is there anything else you would like us to know before your first appointment?

Insurance & Payment Information

Will you be using insurance for therapy services?

Yes No, I will self-pay Not sure yet

If using insurance, please provide the name of your insurance provider:

Insurance ID Number:

Group Number (if applicable):

Insurance Phone Number (usually on back of card):

Name of Primary Insured (if not you):

Primary Insured's Date of Birth (if not you):

Your Relationship to the Primary Insured:

Instructions

Personal Information

Reason for Seeking Therapy

Mental Health History

Medical & General Information

Therapy Preferences

Insurance & Payment Information