New client intake form - Debbie Disney, LCSW-C 2025

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The document is a New Client Intake Form for Positive Changes Counseling Center, designed to collect confidential information from clients prior to their first therapy session. It includes sections for personal details, health and mental health history, family mental health background, and additional information regarding employment, education, spirituality, strengths, weaknesses, and therapy goals.

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Click ‘Get Form’ to open it in the editor.
Begin by entering your name in the designated fields for Last, First, and Middle Initial. If you are under 18, include your parent or guardian's name.
Fill in your birth date and age, followed by your gender. This information is essential for demographic purposes.
Provide details about your primary insurance policy holder, including their birth date. Ensure accuracy for billing purposes.
Complete your address and contact information. Indicate whether messages can be left on your home and cell phones.
Answer questions regarding previous mental health services and current medications. This helps in understanding your history.
Rate your physical health and sleeping habits using the provided scale. Include any specific issues you may have.
In the family mental health history section, indicate any relevant conditions within your family and their relationship to you.
Finally, reflect on personal strengths, weaknesses, and therapy goals to provide a comprehensive view of yourself.

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How do I create a client intake form in Word?

Intake forms can be made in Word by following these steps: Step 1 : Open Microsoft Word. Step 2 : Make a new document. Step 3: Add form fields. Step 4: Customize the details of the form. Step 5: Keep the form safe. Step 6: Send it out and save it.

How do I create a therapy intake form?

Essential components of an effective therapy intake form Patient demographics: Basic information such as name, age, gender, and contact details. Medical history: Including past medical conditions, surgeries, and allergies. Reason for seeking therapy: Understanding the patients primary concerns and goals for treatment.

What should be included on a client intake form?

Intake forms examples and templates you can use for your clients Basic information: Full name. Company name. Contact details (phone, email, address) Service requirements: Type of service required. Goals or expectations from the service. Budget (optional) Additional notes or questions: Free text field.

How to make a client intake form on Google Docs?

Navigate to your Google Forms. Click the Blank form button to start a new form. Title your form appropriately and also offer a helpful description for your recipients. Edit the default, untitled question to gather the name of your client/customer/patient. Select the Short answer question format.

How do I create a client intake form?

Create a client intake form using a fillable PDF. Launch Acrobat. Click Tools Prepare Form. Select a file or scan a document. Add new form fields. These form fields can ask for a name, email, reason for requesting services, and more. Click Distribute to collect responses automatically.