Client Intake
CLIENT INTAKE FORM DATE: _____________
Name: __________________________________ DOB: ____________
Social Security # ________________ Gender F M Age: ____________
Street Address: ________________ City: ______ State: ___ Zip: _____
Home phone: __________ Cell: ___________ Email: ________________
Occupation: ______________ Employer: _________________________
Other people living in the home: (name, age, relationship)
_________________________________________________________
_________________________________________________________
Marital status: M S D Significant other’s name: ____________________
Emergency contact person and Phone: _____________________________
Have you received mental health services before? Y N
If so, with whom, when, and for how long? _____________________ _________________________________________________________
_________________________________________________________Have you ever been treated for chemical dependency? Y N
If so, what substance, when, and for how long? _________________
_________________________________________________________
What, if any, medications are you taking? __________________________
What would you like to get from therapy? _________________________
_________________________________________________________
Who may I thank for the referral? ______________________________
Person responsible for the bill (if different from the client):
Name: __________________________________ DOB: ____________
Social Security # ________________ Gender F M Age: ____________
Street Address: ________________ City: ______ State: ___ Zip: _____
Home phone: _____________ Cell: ___________ Work: _____________
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I understand that all charges are due at the time of service, and that I am fully responsible for all charges incurred. I also understand that I am responsible to pay for missed appointments unless they are rescheduled within the same week.
Signed: _________________________________ Date: _____________
Click Here to Download The Client Intake Form
