Client Intake Form

A confidential intake form to help you gather key information at the start of the therapeutic relationship. Adapt the fields to suit your way of working.

Client details

Full name

Date of birth

Address

Phone number

Email address

Emergency contact (name & phone)

Session preferences

Preferred format

In-person

Online

Telephone

Preferred days / times

What brings you to counselling?

In your own words

Background

Current symptoms or difficulties

Relevant medical history & medication

Previous counselling / therapy experience

Current support network

Risk screening

Please ask directly and record responses. This information is kept confidential and shared only where safeguarding requires.

Thoughts of suicide or self-harm?

Yes — passive

Yes — active

Details / risk plan

Consent & agreement

I have read and understood the confidentiality policy.

I consent to the secure storage of my records.

I understand the cancellation policy.

I consent to begin counselling sessions.

Client signature

Date

Therapist signature

Date