Therapy Intake Form-0

Therapy Intake Form

Welcome. We're glad you're here.

This form helps us understand your background and needs before your first session. Your responses are confidential and will only be used to provide you with the best possible care.

Please take your time — there are no right or wrong answers.

Full Name
Email Address
Phone Number
Date of Birth
What brings you to therapy? Please briefly describe your current concerns.
Have you experienced any of the following? (Select all that apply)
Please describe any relevant mental health history (previous diagnoses, hospitalizations, or prior therapy).
Current medications (if any)
Are you currently seeing any other mental health professionals?
Emergency Contact Name
Emergency Contact Phone
I consent to the intake process and understand my information will be kept confidential.
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