Counseling Intake Form Template

First sessions go better when you already know why someone booked. This counseling intake form template helps relationship and couples therapists gather contact details, goals, and background before the first visit, without a paper packet in the waiting room.

Great for

• Relationship and couples therapists onboarding new clients
• A pre-session link sent after booking the first appointment
• Solo practitioners who want intake answers before the first hour

Skip clinic-style medical and insurance grids on a relationship intake. Focus on goals, stressors, and how the client wants to work together, which is what shapes the first few sessions.

Send the form before the visit so you can skim answers on your phone. Export responses to CSV when you want a simple client record outside your notes app.

Questions in this template

1. Full name *
   Name
2. Email *
   Email
3. Phone number *
   Phone
4. Preferred method of contact *
   Multiple choice Phone call, Text message, Email
5. Date of birth *
   Date
6. Home address *
   Long text
7. Relationship status
   Dropdown Single, Dating, Married or partnered, Separated, Divorced, Widowed, Prefer not to say
8. How long have you been in your current relationship?
   Short text
9. Partner's name (if attending together)
   Name
10. Emergency contact name *
    Name
11. Emergency contact phone *
    Phone
12. Relationship to you *
    Short text
13. Why are you seeking counseling right now? *
    Long text
14. What do you hope to get from counseling? *
    Long text
15. Have you worked with a counselor or therapist before? *
    Yes or no
16. If yes, therapist or practice name
    Short text
17. If yes, what did you work on?
    Short text
18. Which of these feel present for you lately?
    Checkboxes Communication with my partner, Trust or jealousy, Conflict that keeps repeating, Life transition (move, job, family), Grief or loss, Feeling distant or disconnected, Parenting stress, Something else
19. Average hours of sleep per night
    Short text
20. Preferred session times
    Dropdown Weekday mornings, Weekday afternoons, Weekday evenings, Weekends, Flexible
21. Anything else we should know before we meet?
    Long text
22. Signature (type your full name) *
    Short text
23. Today's date *
    Date