Templates Health & Wellness Medical Online Therapy Intake Form Template

Online Therapy Intake Form Template

Use This Template
Please enable JavaScript in your browser to complete this form.

Personal Information

Full Name

Mental Health History

Presenting Concerns

Consent and Policies

Clear Signature

The Online Therapy Intake Form Template by WPForms is designed for healthcare providers, clinics, and organizations offering telehealth services that want a streamlined method for collecting new client information.

How Does the Online Therapy Intake Form Template Work?

The Online Therapy Intake Form Template requires the WPForms Pro License and the Signature Addon to collect vital client information and acquire their consent for receiving medical assistance online. Fields include:

  • Personal Information:
    • Full Name: Records the name to start a personal connection with the client.
    • Date of Birth: Important for demographic records and treatment plans.
    • Your Gender: To understand the client better and address them appropriately.
    • Email Address: Essential for sending appointment reminders/therapy resources.
    • Phone Number: Direct line for urgent communications/therapy reminders.
  • Mental Health History:
    • Previous Therapy Experience: Gives insights into what has been tried before.
    • Mental Health Diagnosis: Crucial for understanding the client’s current health status.
    • Family Mental Health History: Offers valuable context regarding genetic factors.
  • Presenting Concerns:
    • Reason for Seeking Therapy: Directs the therapy goals and areas of focus.
    • Goals for Therapy: Helps in setting clear expectations and benchmarks for progress.
  • Consent and Policies:
    • Consent Checkbox: Ensures clients understand and agree to the therapy terms.
    • Signature and Date: A formal acknowledgment from the client.

Sign up with WPForms today and access the Online Therapy Intake Form Template. It is ideal for therapists, counseling centers, and mental health professionals looking to modernize and streamline their client onboarding process.