Counseling Intake Form

Full Name*

Email Address*

Phone Number*

Date of Birth*

Emergency Contact Name & Phone*

Reason for Seeking Counseling*

Anxiety

Depression

Relationship Issues

Grief / Loss

Stress / Burnout

Trauma

Self-Esteem

Other

Describe Your Current Concerns*

Have you received counseling or therapy before?*

Current Medications

Goals for Therapy

What is this form?

A counseling intake form for mental health professionals to gather client background, presenting concerns, and relevant history before the first session.

Who is it for?

Therapists, counselors, social workers, and mental health practices that need to collect comprehensive client information prior to initial appointments.