Cognitive biases
Client Intake Form
Client Intake Form
This directive structures the initial data collection phase for a new client, designed to produce a comprehensive clinical snapshot before or during the first session. Its purpose is to establish a solid foundation for case conceptualization and initial treatment planning. The form helps you efficiently gather the necessary background information, ensuring key clinical domains are not overlooked when starting with a new case.
The instrument functions as a preliminary assessment, flagging immediate risk factors while clarifying the client’s stated objectives for treatment. It helps define client expectations and boundaries from the outset, which directly informs the therapeutic contract. This systematic approach provides a documented baseline for defining the treatment focus and measuring subsequent progress against the client’s own initial goals.
Client Intake Form
| Confidentiality: The information you provide on this form is confidential and used for professional purposes. It will not be disclosed to third parties without your written consent, except where required by law (e.g., risk of harm to self or others, child abuse). |
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| State the primary problem you are seeking help for at this time. |
| Previous therapy or counseling experience? If yes, provide a brief summary. |
| What specific, observable changes would tell you that therapy has been successful? |
| Current medications or other medical treatments? If yes, list them. |
| Previous mental health diagnoses? If yes, list them. |
| List any significant current stressors. |
| Recent traumatic events or significant life changes? If yes, describe. |
| Are there cultural, religious, or spiritual factors relevant to your problem or its solution? |
| Do you have specific expectations or concerns about the therapy process? |
| Are there any topics you are not willing to discuss at this time? |
| List any known allergies or medical sensitivities. |
| History of self-harm or suicidal ideation/attempts? If yes, provide details. |
| Current involvement in any legal proceedings? If yes, specify. |
| Do you have any concerns about confidentiality? If yes, specify. |
| Is there any other critical information needed to understand your situation? |
| Referral source: |
| Note any financial or insurance matters that require discussion. |
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