The form buys back the first session. If a client arrives having already listed their medications, their last therapist and their insurance details, the hour goes to the reason they came. It also gives you a first look at screening scores and history before you sit down together, so you can plan the questions that matter.
Most practices send it through the client portal a few days ahead and ask the client to finish it before the appointment. Someone on the clinical side should read it before the client walks in, for reasons covered under common mistakes below.
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Patient registration form | | Name, address, date of birth and billing details only |
Counseling intake form (this page) | Client, before the first session | Contact preferences, insurance, emergency contact, a short history, screening scores, goals |
| | Longer open questions about history, relationships and goals |
Therapy intake assessment | Clinician, after the first session | Clinical findings, risk, working diagnosis and plan |
Biopsychosocial assessment | Clinician, often over more than one session | A full history across health, psychological and social areas, with a formulation |
See the patient registration form, intake questionnaire, therapy intake assessment and biopsychosocial assessment templates.
- Contact details and how the client wants to be reached: which number, whether you may leave a voicemail, and whether email or text is fine.
- Insurance: plan, member ID, and the subscriber's name and date of birth when the client is covered as a dependent.
- Emergency contact, with what the client is willing for you to tell that person.
- What brings you in, in a few lines, and why now.
- A symptom checklist or standard screeners such as the PHQ-9 for depression and the GAD-7 for anxiety.
- Past counseling, psychiatric care and hospital stays.
- Current medications, the prescriber, and the primary care provider.
- Alcohol, drug, nicotine and caffeine use.
- Home, work or school, and any worries about money, food or housing.
- What the client hopes will be different after counseling.
- Signature and date, with the practice's consent and privacy documents attached.
Luis is a fictional client. Every answer below is invented for illustration.
Name and pronouns: Luis, 22, he/him. College junior, studying mechanical engineering.
How to reach me: Cell phone. Voicemail is OK, but please say only the clinician's first name and not that it's a counseling office. Email is fine for scheduling, not for anything else.
Insurance: Covered on his mother's employer plan. Subscriber name and date of birth entered; member ID from the card photo he uploaded.
Emergency contact: His roommate, Theo. Luis checked the box allowing the practice to tell Theo whether he is safe, and nothing else.
What brings you in: "I freeze before exams and I've stopped going to my 8 a.m. class. My advisor said I should talk to someone."
Screening: GAD‑7: 15. PHQ‑9: 8, with item 9 (thoughts of being better off dead or of self‑harm) answered "not at all."
History: A few sessions with a school counselor in tenth grade. No psychiatric medication, no hospital stays. Albuterol inhaler as needed for asthma.
Substances: Three or four drinks on Saturdays. Vapes daily. Four energy drinks a day during exam weeks.
Living situation and money: Campus apartment with one roommate. Works 12 hours a week at the library. "Rent is covered but I skip meals at the end of the month."
Goals: "Get through finals without panicking. Go back to my morning class."
What the clinician takes from it: The GAD‑7 score, the energy drinks and the skipped meals go on the agenda for the first session. If the clinician confirms the food concern and signs off on it in the record, it can support Z59.41, Food insecurity (see the coding note below).
Copy the questions below into your form builder or onto letterhead. The prompts in brackets show the kind of answer you're after.
- Name, date of birth, pronouns:
- Address and phone:
- How should we contact you? [preferred number; OK to leave a voicemail? yes / no; OK to email or text? for what?]
- Insurance: [plan, member ID, subscriber's name and date of birth if not you]
- Emergency contact: [name, relationship, phone; what we may tell them]
- What brings you to counseling now?
- Screening questionnaires: [attach the ones you use]
- Past counseling or psychiatric care: [when, with whom, did it help?]
- Hospital stays for mental health or substance use:
- Current medications and who prescribes them:
- Primary care provider:
- Alcohol, drugs, nicotine, caffeine: [what, how much, how often]
- Who do you live with? Work or school?
- Any worries about money, food or housing?
- What would you like to be different after counseling?
- Signature and date:
Privacy questions to ask on day one
Two HIPAA rights are easiest to respect when the intake form asks about them.
Confidential communications. A client may ask to be contacted at another number or address, or by another method, and a provider must accommodate reasonable requests and can't require the client to explain why (45 CFR 164.522(b)). A voicemail checkbox and a preferred‑number line handle most of these requests before they come up.
Family and emergency contacts. When the client is present and able to decide, you may share relevant information with a family member or friend involved in their care if the client agrees, or if the client is given the chance to object and doesn't (45 CFR 164.510(b)). Writing down who the emergency contact is, and what the client is happy for you to tell them, saves a hard decision during a crisis.
Answers about food, housing or money are more than background. The FY2027 ICD‑10‑CM Official Guidelines allow social determinants of health codes, mostly found in categories Z55 to Z65, to be assigned from information the patient reports, as long as a clinician or provider signs off on it and it's incorporated into the medical record (CMS, FY2027 guidelines, section I.C.21.c.17). An unreviewed answer on a portal form doesn't meet that bar until you've reviewed it and added it to the chart.
- Asking about suicidal thoughts with nobody assigned to read the answer before the session. If the form asks, someone on the clinical team reviews it in advance and acts on a positive response.
- Asking the client to name their diagnosis. You'll get whatever a past provider told them, which may be out of date.
- Repeating the same questions on the registration form, the intake form and the questionnaire.
- No place for contact preferences, so the first voicemail goes to a shared family phone.
- Missing the subscriber's details when the client is a dependent on someone else's plan, which leaves the claim incomplete.
The client still fills in the form; Twofold picks up at the session that follows. Choose the Intake (Mental Health) template, record the first session, and Twofold drafts your intake note from the conversation. Compare it with the form before signing, especially the medication list and screening scores, which clients often correct out loud. More on drafting on the AI therapy notes page.
Therapy intake assessment template, intake questionnaire template, patient registration form template, insurance verification form template, consent form template and biopsychosocial assessment template.
Reviewed and updated October 2026.
