Psychotherapy Intake

Please complete the form below. Once finished, you can download a PDF copy for your records before submitting it.

Psychotherapy Intake Form

Please fill out the following completely as possible. All material is confidential.

Personal Data Sheet

Name *

Address *

Ok to write to you at this address? Yes No

Personal Phone *

Business Phone (Optional)

Ok to call you at either of these? Yes No

Client E-mail *

At what time can we reach you at either of these phones?

Age

Birthday

Sex

Foreign-born arrival date (if applicable)

Are you a citizen?

Birthplace

Time in Current City

Marital Status

How long ago?

If separated or divorced, when?

If married more than once, list dates and details:

Are you in any romantic relationship? (if single/divorced)

How healthy is the relation?

List number and ages of children, if any

Occupation

Approximate gross yearly salary

How long have you been doing present kind of work?

If unemployed, source of income:

How far through school did you go?

Name and address of nearest relative or friend

Condition/Purpose for treatment

Whom are you living with at present?

Who referred you here?

How strongly do you want treatment for your problem?

Preferred Therapy Option

Online In-person office Hybrid

What days and times can you come here/be available?

Object to psychologic tests if necessary?

Do you know what psychotherapy is?

What is your expectation for this therapy session?

Fees and Payment Plan

Fee per session

Total Fee (to be filled by therapist/planned)

Payment Plan

Date envisage to start session

NOTE: The client shall have two sessions per week with each session lasting 60 minutes.

Important Issues

What you hope to achieve

Personal Profile

1. I would describe myself as:

2. Others would describe me as:

3. Some of my hobbies/interests are:

4. The one thing I would like most to accomplish (but haven't yet) is:

5. The one thing I wish I could change in the short-term is:

6. I think that the most important thing in life is:

7. I am interested in working with a Psychotherapist because:

Generated on: ---

Confirmed by Client Signature (Original)

Ref: ---

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