Intake, classic form
Therapy intake template
A first session intake for counselling with referral, reasons, a two week symptom grid, history, a safety question and consent to fees and confidentiality.
16 questions, 9 required, as a classic form
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Every question
Name (required)
Full name
Pronouns and the name you go by
Short answer
Date of birth (required)
Date
Mobile, and whether we may leave a voicemail (required)
Short answer
Email, and whether we may email you (required)
Short answer
Emergency contact, relationship and phone (required)
Short answer
GP name and practice
Short answer
Referred by (required)
Single choice: GP with a Mental Health Treatment Plan, Self, Employer EAP, NDIS, Other
In your own words, what brings you to counselling now?
Long answer
What would you like to be different in three months?
Long answer
Over the last two weeks, how often have you
Rating grid
Previous counselling or psychiatric care
Single choice: None, Some, Ongoing elsewhere
Current medications
Long answer
Have you had thoughts of harming yourself in the last month? (required)
Single choice: No, Yes, Prefer to discuss in session
I have read the above and consent to counselling (required)
Multiple choice: I consent
Signature (required)
Signature
What you fill in
- [Your company]