Therapy and mental health intake form
A mental health intake form helps a therapist or counselor understand what brings a client to their first session — their presenting concerns, whether they've been in therapy before, and critical emergency contact information. This prepares the clinician to tailor the initial conversation.
The form beside this text is live. Fill it in and submit it — it validates exactly as it would for a real respondent, and saves nothing.
The crisis notice appears first and is unmissable
If a client is in crisis, they see the 988 lifeline resource immediately and know this form is not for emergencies.
Emergency contact upfront lets the therapist reach someone if the client is unsafe
Collecting this early prevents fumbling in a crisis; it's standard clinical practice.
No card required.
Mental Health Intake Form
Live previewHow to build this form
8 steps in the editor. Nothing here needs a paid plan.
- Start with a crisis notice paragraph (required by safety guidelines).
- Add text and email fields for client name and email.
- Add a date field for date of birth.
- Add a phone field for client contact.
- Add text fields for emergency contact name and phone number.
- Add a textarea for "what brings you in?" — ask for the client's own words, not a diagnosis.
- Add a radio for previous therapy experience (yes/no).
- Add an optional textarea for current medications.
Fields in this form
10 fields, using 7 of the 19 field types available.
| Question | Field type | Required |
|---|---|---|
| This form is not for emergencies. If you are in crisis or having thoughts of self-harm, please call or text 988 (US) or your local emergency number now, rather than waiting for a reply to this form. | Simple Paragraph | Optional |
| Full name | Short text | Yes |
| Email address | Yes | |
| Phone number | Phone | Yes |
| Date of birth | Date | Yes |
| Emergency contact name | Short text | Yes |
| Emergency contact phone | Phone | Yes |
| What brings you in? (In your own words) | Long text | Yes |
| Have you seen a therapist or counselor before? | Radio buttons | Yes |
| Current medications or supplements (optional) | Long text | Optional |
What goes wrong with this form
Specific to a therapy and mental health intake form, not general advice about forms.
Asking the client to self-diagnose ("Do you have anxiety?") instead of asking what they're experiencing
The therapist diagnoses; the form captures what the client reports. Frame it as "What concerns have brought you here?" not "What disorder do you have?"
Omitting emergency contact information
This is critical for safety. Always collect emergency contact name and phone before the first session.
Removing or downplaying the crisis notice
This form is not for emergencies. Keep the crisis notice prominent so someone in crisis routes to 988 instead of waiting for a form response.
Questions about this form
Should I ask for a DSM diagnosis in this form?
No. Ask for the client's own words — "What brings you in?" — rather than asking them to diagnose themselves. The therapist will assess and diagnose in the session.
Is this form HIPAA-compliant?
This is a general intake form, not a clinical record system. If you operate under HIPAA, you are responsible for compliance.
Is this form for people in crisis?
No. This form is not for emergencies. If you are in crisis or having thoughts of self-harm, call or text 988 (US) or your local emergency number now — a form response can take hours or days, and the crisis notice at the top of the form says so.
Other templates
- Patient intake formInsurance provider and ID as their own fields, so registering doesn't start with a phone call.
- Medical HistoryCollect a new patient's medical background before the first appointment.
- Insurance VerificationCollect insurance details before the appointment so staff can verify coverage manually.