What to include in a therapy intake form

The intake form is your first record of a new client and your first chance to agree on how you will work together. A good one collects what you need, and no more, and gets consent in writing. Here is what to include.

Contact and basics

• Full name, date of birth, address, phone and email.
• Preferred name and pronouns.
• Whether it is safe to leave a message, by phone or by email.
• An emergency contact, and permission to use it.

Why they are coming

• The main concern in the client's own words.
• How long it has been present and what they have tried.
• Current goals for therapy.

Relevant history

• Previous therapy or counseling.
• Current medications and the prescriber.
• Medical conditions that affect care.
• Current safety concerns. Ask in a way that tells the client how you will respond.

Agreements and consent

• Informed consent to treatment. What therapy involves, its benefits and risks, and confidentiality and its limits.
• Fees and payment. Your session fee, how you are paid, and your cancellation policy.
• Privacy notice. If HIPAA applies to you, clients also need your Notice of Privacy Practices.
• Telehealth consent. If you offer video, cover the limits of the technology and what to do if it fails. See HIPAA and telehealth.
• Communication preferences. Whether you may text or email, and what you use each for.

For clients who want reimbursement

If you give superbills, you will need the client's date of birth and address for the document, and a diagnosis is added by you after the assessment, not asked on the form. If a client is paying for themselves without insurance, a Good Faith Estimate is also part of the start of care.

Keep it short

Long forms tire clients and lower the quality of answers. Ask only what you will use, and cover the rest in the first session. Send the form ahead of time so the first hour is for the conversation, not the paperwork.

Send it online

A digital form can be completed on a phone before the visit, signed electronically and stored in the client record, which avoids re-typing. In RafaNest you can build your own forms, send an intake form automatically to every new patient, and collect an electronic signature. See how the intake forms work.

The exact consent language depends on your profession and state. Ask your licensing board, your professional association or an attorney to review your forms. This is general information and not legal advice.