Template library · Intake forms
Adult Counseling Intake template
Please complete before your first session.
- 16 fields across 3 sections
- Included with MyWellOps
- Edit it, or save your own version
What’s in it
- DateDate
- PractitionerText
Client Information
- Full nameText
- Date of birthDate
- Phone numberText
- EmailText
- Emergency contact (name & phone)Text
Presenting Concerns
- What brings you to counseling?Text
- How long have you been experiencing this?Choice
- How would you rate your overall mood lately?Text
- Have you attended therapy before?Choice
Background & Goals
- Current medicationsText
- OtherText
- What would you like to work on in counseling?Text
- Client signatureSignature
- Date signed (client)Date
- Have you experienced any of the following? (check all that apply):
- Anxiety
- Depression
- Trauma/PTSD
- Substance use
- Grief/loss
- None of the above
When to use it
Send an intake form when a new client books, so their history, contact details and reasons for coming are in front of you before the first appointment rather than taken down during it.
How it works in MyWellOps
- Choose it from Documents and adjust the questions to your practice.
- Send it to the client, who completes it in their client portal.
- Their answers are kept on the client’s record, ready for the first session.
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