Client Intake Form - Part 1

Welcome! As part of beginning the therapy process, please take a few minutes to fill out this form. This information will help me better understand your situation/history and will help us both find solutions to the situations that are creating difficulties. Please note that this information is confidential.

Date:

Type of therapy sought:

Name of person filling out the form:

Name of Primary Patient ( if different):

Bithdate

Gender

Employer | School

Position | Year in school

Source of Stress: What are the primary issues for which you are seeking Therapy?

What are the most important things you think I should know about these issues?

In what way have you attempted to cope with these issues?

Do you have any particular concerns or fears regarding therapy?

What are your goals for therapy?