Templates Health & Wellness Medical Counseling Intake Form Template

Counseling Intake Form Template

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Client Name
Mailing Address


Emergency Contact's Name




How Did You Hear About Us?

Do you need to screen potential clients for counseling services? Then you should check out the Counseling Intake Form Template from WPForms.

This form template is great for educators, counselors and therapists, social workers, and anyone else who offers counseling. Our template comes with all of the fields you need to get started, while also being 100% customizable.

What Goes Onto a Counseling Intake Form?

A Counseling Intake Form should gather all of the information related to a potential client and their healthcare provider. This form template includes all of that and more. Our Counseling Intake Form first collects the client details with the following fields:

  • Date
  • Client Name
  • Date of Birth
  • Sex (dropdown selection)
  • Email
  • Phone
  • Mailing Address
  • Current or Previous Occupation
  • Marital Status (dropdown selection)
  • Reason for Appointment

Next, this form template gathers the emergency contact information with these fields:

  • Emergency Contact’s Name
  • Contact Number
  • Relationship to Client

Then, our form template covers the healthcare details with the following fields:

  • Current Healthcare Provider
  • May We Send Them Information? (Yes or No)

The insurance provider information is included next, with the form user filling out these fields:

  • Group Number
  • ID Number
  • Subscriber
  • Employer
  • Date of Birth
  • #SS
  • Relationship to Client

Lastly, the form template gathers referral details with a multiple choice field. The form asks, “How Did You Hear About Us?” and the user makes a selection from the following options:

  • Internet/Search Engine
  • Friend Referral
  • Social Media
  • Referral
  • TV/Radio
  • Third-Party Review
  • Other

Form users are given the option to include additional questions or comments, and are provided with plenty of space to type at the bottom of the form.

Get started with WPForms today to create and customize your own Counseling Intake Form. Signing up with WPForms gives you access to this and hundreds of other pre-made templates.