Therapeutic Intake form examples

Client name:                                                   Date: 

            Thank you for contacting me to make an appointment.  I support your decision to take this step forward in your therapeutic journey.  Taking responsibility for your own health is one of the most important parts of creating wholeness, peace and fulfillment in your life.  My intention is to support you as I am best able with respect for you and your needs during the session. Please answer all the sections of the intake form with which you feel comfortable.  The information helps me connect with your as well as your successes in life, and can be a guide to our work together.  All information shared on the form and in every session is strictly confidential, and never shared with another party without your written permission.

            The basics of a first therapeutic session will include a brief period of talking, where you share information on your health, both past and current, and discuss physical issues that are present in your life. 

I am not trained as a medical doctor and I do not diagnose any medical condition, suggest any medical treatment, or prescribe or recommend any medication.  I do recommend you have a healing team which includes a physician.

            My cancellation policy is as follows:  I request notification of cancellation a minimum of 24 hours before the session.  Exceptions are made for health and family emergencies.  First-time cancellation with less than 24 hours, or no-shows, will be charged $35.  For any subsequent late cancellation or no-show, the full session fee of $85 will be charged.  Please make checks payable to....

            I look forward to working with you.

CLIENT INTAKE FORM

(Confidential- For Practitioner's Use Only)

Name: ____________________________________            today's date: ________

Address: ____________________________________         D.O.B._____/_____/_____

___________________________________________          Height: _____ Weight: _____

Phone-Home: _______________ Work: ________________ Cell: _______________________

Passion: ________________________________   Occupation: _________________________
Occupation: ___________________________________________________________________

Emergency Contact: ________________________ Relation: ___________ Phone: _________

Current Relationship Status: ____________________ # of Children and Ages: ____________

Current Living Situation: With Self, Pets, Friend(s), Roommate(s), Partner/Spouse, Family, Other

__________________________________________________________________________

Referred By: ________________________________________________________________

Have you ever been hospitalized? ____________ When? __________________

If so please describe circumstances: _______________________________________________

Reason for this visit: ___________________________________________________________

____________________________________________________________________________

Onset date_____/_____/______ Sudden or slow onset: _____________
Surrounding circumstances if known: ______________________________________________

____________________________________________________________________________

Current or previous treatment for above: ____________________________________________

____________________________________________________________________________

Current medications/Supplements: ________________________________________________

____________________________________________________________________________

History of medications (antibiotics, frequency, etc):___________________________________

____________________________________________________________________________

Allergies: ____________________________________________________________________

Other allergies: ________________________________________________________________

Eating Habits/Diet: _____________________________________________________________

____________________________________________________________________________

Daily Intake: Water________ Caffeine____________ Alcohol__________ Tobacco________

CLIENT INTAKE FORM

(Confidential- For Practitioner's Use Only)

Exercise Routine (type/frequency) ________________________________________________

____________________________________________________________________________

List any injuries you have had and when they occurred (broken bones etc.)___________

____________________________________________________________________________

____________________________________________________________________________

List any surgeries you have had and when they occurred __________________________

____________________________________________________________________________

____________________________________________________________________________

Llist any traumatic and life-threatening events that occurred in your life and when they happened. 

______________________________________________________________________

CLIENT INTAKE FORM

(Confidential- For Practitioner's Use Only)

What are your hopes and expectations for this session, and for long-term sessions?

This session: ___________________________________________________________

______________________________________________________________________

Long-term:  ____________________________________________________________

______________________________________________________________________

Are your bowel movements daily ? ________________________
Please share any other illness or disease you have experienced in any of the following areas:

Emotional/Psychological:

Neurological:

Cardiovascular:

Urinary:

Auto-Immune:

Musculo-Skeletal-Skin:

Respiratory:

Reproductive:

Endocrine:

Ear, Nose, Throat:

Digestion:

Childhood Diseases:

Other:

List anything else you wish to communicate which was not covered in this form.