How to create a counseling intake form that stands out

Intake forms are an integral component of nearly all medical practices for a good reason. They allow counselors to verify they can provide timely assistance when needed. Whether you're just getting started or have been in business for a while, an efficient counseling intake form is crucial to the success of your practice. We'll be breaking down the components of a good intake form for counseling services below.

What is a counseling intake form?

Mental health professionals can collect crucial information from new patients with the help of an intake form. A counseling intake form can help you get started in the right direction by gathering important information about the patient's goals. The time spent gathering necessary patient details before the first meeting can be used better.

How important is it to have a counseling intake form?

A counseling intake form is extremely valuable to the practitioner for several reasons:

  • It provides documented answers to important questions

  • It highlights your patient's past interactions with other therapists and doctors

  • It reveals a patient's entire medical history

  • It shows a patient's treatment goals

How to create a counseling intake form

A counseling intake form can be obtained in two ways: from scratch or by customizing an existing form. If you want to design your own intake form, you must include all the important questions. Here's a list of questions to ask to avoid the risk of leaving out vital information.

Counseling intake form questionnaire

Look at this extensive set of questions that could be included on your intake form.

General section

Here are some fields you might want to include in your general section:

Patient information

  • The birthdate

  • Name and surname

  • Gender Pronouns of Preference

  • Address (City and Zipcode)

  • Preferred mode of communication (email, phone number, social media contact)

  • Phone number (Home and Work) and preferred number to leave a private message

Work status

  • Occupation\Industry

  • Company name and location (City and Zipcode)

  • Employment type (self-employed, unemployed, retired, etc.)

Who to call in case of an emergency

  • Name of emergency contact and phone number

  • Relationship with patient

Additional questions

  • Ethnicity

  • Sexual orientation (Marital status)

  • Education Level

  • Level of income

Reasons for seeking counseling

  • Goals for counseling

  • What do you wish to achieve due to counseling?

Health and medical background

  • Past and current health issues

  • Past and current medications

  • History of abuse or trauma (physical, emotional, mental, or sexual)

  • Name of primary care physician and contact number

  • Name of psychiatrist and contact number

Some questions to include:

  • Have you ever been hospitalized for a psychiatric illness?

  • Is there anyone in your family who has been hospitalized due to mental illness?

  • Is there a history of mental illness in your family?

  • Have you ever attempted suicide?

  • Has anyone in your family attempted or committed suicide?

  • Have you struggled with substance abuse?

  • Does anyone in your family have substance abuse problems?

  • Do you have any criminal record?

  • How well are you doing with family relationships?

  • How is your current mental health?

  • Do you have any current life transitions and issues you would like to share?

  • How would you describe your state of well-being right now?

Symptom evaluation

In the symptom evaluation section of your counseling intake form, you could include a list of things, including:

  • When the patient first noticed the symptoms

  • What kind of symptoms is the patient experiencing

  • Progression of the symptoms

  • Frequency of the symptoms

  • Duration of the symptoms

Medical treatment authorization form

Counseling intake forms should include a legal consent for treatment section that details appointment duration, fees, and payment policies. Confidentiality rules between you and your patient are an important part of this. Possible things to include in this section:

  • Overview of the treatment plan

  • Training and clinical supervision

  • Requirements to sufficiently provide treatment

  • Rights of the patient

  • Responsibilities of the patient

  • Fees and appointments

  • Confidentiality agreement

  • Patient consent, including name, date, date of birth, and signature

Consent to use or disclose health info

  • Patient's name and address

  • Contact number

  • Overview of consent to use or disclose health information for treatment, payment, and health care operations

  • Understanding and acknowledgment of consent

  • Patient name, signature, and date

  • Patient's representative name, signature, and date (if necessary)

Financial agreement

  • Client name and address

  • Phone number and email

  • Services provided

  • Duration of services

  • Costs of services

  • Method and proof of income

  • Your signature

  • Patient signature and date

Wrap up

The quality of your intake form is critical to the success of your private practice. Also, ensure that your counseling intake form meets all security requirements and compliances. Finally, having potential patients fill out your intake form ahead of time ensures readiness to begin the treatment as early as possible and invites a sense of confidence in the counselor and therapeutic process.

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