New client intake questionnaire template

New Client Intake Form

Contact details

Full name · Date of birth · Phone · Email · Emergency contact name & phone · GP name & clinic (optional)

Presenting concern

What brings you to counselling at this time? · How long has this been a concern? · What would you like to be different by the time we finish working together?

Background

Have you seen a counsellor, psychologist or psychiatrist before? When, and was it helpful? · Are you currently taking any medication relevant to your mental health? · Any significant medical conditions your counsellor should be aware of? · Current living situation and important relationships (partner, family, dependants) · Employment/study status

Safety screening

Are you currently having any thoughts of harming yourself or ending your life? · Have you had these thoughts in the past? · Do you feel safe in your current living situation? · Is there anyone else you're worried may harm you?
(These are general screening questions to open a conversation, not a validated risk-assessment instrument — use your own clinical judgement and your practice's risk protocol for any follow-up.)

Goals & preferences

What are you hoping to get out of counselling? · Is there anything about your background (cultural, religious, LGBTQIA+, disability) you'd like your counsellor to understand or be mindful of? · Preferred session format: in-person / telehealth / either

Consent

I confirm the information above is accurate to the best of my knowledge, and I consent to [practice name] collecting and holding this information as described in the practice's privacy policy. Signature: ______________________    Date: __________