A therapy intake form collects what you need before the first session. It covers who the client is, how they will pay, why they are coming in, their history and risk, and their consents. Copy the template below, cut what your practice does not use, and send it to clients before the first appointment.
Two parts of the intake packet are set by federal rules: the privacy notice acknowledgment and, for self-pay clients, the Good Faith Estimate. Both are covered below.
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You review and sign
START FREE TRIAL →What should a therapy intake form include?
| Section | What it collects | Why you need it |
|---|---|---|
| Client details | Name, date of birth, pronouns, contact details, preferred contact method | Scheduling, reminders, identity on claims |
| Emergency contact | Name, relationship, phone | Who to call if the client is at risk |
| Insurance or payment | Plan, member ID, subscriber, or self-pay | Eligibility check and billing |
| Reason for seeking therapy | The problem in the client's words, how long, what prompted them now | Starting point for the assessment |
| Mental health history | Past therapy, diagnoses, hospitalizations, current medications and prescriber | Context and care coordination |
| Medical history | Conditions, allergies, primary care provider | Rule out medical causes, coordinate care |
| Substance use | Alcohol, cannabis, other substances, frequency | Screening and level of care |
| Safety screen | Current or past thoughts of self harm, harm to others | Flags for review before or at the first session |
| Family and social | Household, relationships, work or school, supports | Context for the treatment plan |
| Goals | What the client wants to be different | First draft of treatment goals |
| Consents and acknowledgments | Privacy notice, consent to treatment, financial and cancellation policy | Required before care starts |
Therapy intake form template
Each line is a prompt for the client. Keep the order, so your team always knows where to look.
Therapy intake form: adult client
- Client details: full name, preferred name, pronouns, date of birth, address, phone, email, okay to leave a voicemail (yes/no), okay to text (yes/no).
- Emergency contact: name, relationship, phone.
- Payment: insurance plan, member ID, subscriber name and date of birth, front and back of card; or self-pay.
- What brings you to therapy now? In your own words. How long has this been going on?
- Past therapy or psychiatric care: when, with whom, what helped, what did not. Any hospital stays for mental health.
- Current medications: name, dose, prescriber. Allergies.
- Medical conditions and primary care provider.
- Alcohol and substance use: what, how often, any concerns.
- Safety: In the past month, have you had thoughts of ending your life or harming yourself? Thoughts of harming someone else? (yes/no, and when).
- Household and relationships: who you live with, important people, supports.
- Work, school and daily life: what is going well, what is hard.
- Goals: what would you like to be different after therapy?
- Anything else you want your therapist to know before the first session.
A form is not a crisis line. Put a line at the top of the safety section: if you are in danger now, call or text 988 or call 911. Then have someone review safety answers before the first session.
Add-ons for minors
Intake add-ons: client under 18
- Parent or guardian: names, legal custody arrangement, who can consent to treatment.
- School: grade, school, any IEP or 504 plan, attendance concerns.
- Development: milestones, early diagnoses.
- Who can receive information: which adults the therapist may speak with.
Add-ons for telehealth clients
Intake add-ons: telehealth
- Location: the address where you will be during sessions, and the state.
- Local emergency contact and nearest emergency room for that location.
- Backup: a phone number to call if the video drops.
- Telehealth consent: agreement to receive care by video, where your state or payer requires it.
Telehealth billing has its own rules for place of service and modifiers. Our modifier 95 guide covers them.
Which forms go in the intake packet?
The intake form is one document. Send it with these:
| Form | When | Source of the rule |
|---|---|---|
| Notice of privacy practices + acknowledgment | By the first session | 45 CFR 164.520 |
| Good Faith Estimate | Self-pay and uninsured clients, after scheduling | CMS, No Surprises Act |
| Informed consent to treatment | Before the first session | State law and your licensing board |
| Financial and cancellation policy | Before the first session | Your practice policy |
| Release of information | When you will share records with another provider | HIPAA and state law |
| Telehealth consent | Before the first video session | State law and payer policy |
Privacy notice acknowledgment
Under 45 CFR 164.520, a provider gives the notice of privacy practices "no later than the date of the first service delivery." The provider must also "make a good faith effort to obtain a written acknowledgment of receipt of the notice," and document the effort if the client does not sign. A checkbox and signature line on the intake packet covers the acknowledgment.
Good Faith Estimate for self-pay clients
CMS says that if a client is not using insurance, "your health care provider must give you a good faith estimate." That applies when they request one or schedule at least 3 business days ahead. The timing depends on how far out the appointment is:
| Appointment booked | Estimate due |
|---|---|
| 0 to 2 business days ahead | Not required |
| 3 to 9 business days ahead | Within 1 business day of scheduling |
| 10 or more business days ahead | Within 3 business days of scheduling |
The rule applies to uninsured and self-pay clients, per CMS provider requirements. Clients billed to Medicare or Medicaid fall under other protections.
mdhub, AI for behavioral health clinics
Intake, notes and billing in one place
BOOK A FREE DEMO →How to get intake forms completed before the first session
- Send the form when the appointment is booked, with a link that works on a phone.
- Ask for each fact once. If insurance details are in the booking request, do not ask again.
- Mark the questions you will go through together in session, so clients can leave hard ones blank.
- Send one reminder before the session, then call if the safety section or consents are missing.
- Read the form before the session. Bring two or three follow-up questions from it.
Intake form vs biopsychosocial assessment
The client fills in the intake form. The clinician writes the assessment, using the form as a starting point. Our biopsychosocial assessment template covers the clinician's part, and the treatment plan template covers what comes after it.
Send intake forms from the same system as your notes
mdhub has custom intake and consent forms with e-signature, plus scored questionnaires like PHQ-9. Sarah, mdhub's AI admissions coordinator, collects intake information when a new client reaches out. Start a free trial, or book a demo if you run a clinic with 10 or more clinicians.
Sources
- eCFR, 45 CFR 164.520, Notice of privacy practices for protected health information
- CMS, What is a good faith estimate?, last modified October 5, 2026
- CMS, No Surprises Act provider requirements and resources, last modified August 20, 2026
Therapy intake form FAQ
A form a new client fills in before the first session. It covers contact and payment details, the reason for seeking therapy, history, a safety screen, goals and consents.
Client details, emergency contact, insurance, reason for seeking care, mental health and medical history, medications, substance use, a safety screen, family and social context, goals and signed consents.
No federal rule requires one specific form. The privacy notice acknowledgment and, for self-pay clients, a Good Faith Estimate have federal rules, and consent to treatment is set by state law.
Before the first session, sent when the appointment is booked, so the clinician can read it first.
The client completes the intake form. The clinician completes the assessment in or after the first session.
Use the same form plus a telehealth section: session location, local emergency contact, a backup phone number and telehealth consent where required.
Yes, under the No Surprises Act, when they ask for one or book at least 3 business days ahead.
