Therapy Intake Form Template for Private Practice (US & Canada)
A therapy intake form collects the demographic, clinical, and payment information you need before a first session. This template covers every field a private practice needs, with HIPAA-aware consent guidance for US practices and a dedicated Canadian section covering PHIPA, PIPEDA, and Quebec’s Loi 25 regime plus insurer fields for Sun Life, Manulife, Desjardins, and Green Shield Canada.
Download the template: Fillable PDF · Editable DOCX. Both are free, no email required. A French version is coming.
What Is a Client Intake Form in Counseling?
A client intake form is the document a new client completes before their first appointment. It does two jobs at once. It gives you a clinical head start (presenting concerns, history, medications, supports), and it creates the legal record your regulator and privacy law require, showing that the client knew what they were consenting to before care began.
In practice, “the intake form” is usually a small packet: a client information form, a consent-to-services agreement, and a privacy notice. This template combines all three. A good intake form is triage, not treatment. It tells you where to look in the first session, and it should never try to do the session’s work on paper. The packet is also where privacy compliance happens. In the US, it carries the privacy-notice acknowledgment HIPAA requires. In Canada, the moment a client writes their name on your form, you are collecting personal health information under PHIPA, PIPEDA, or Quebec’s Loi 25 regime. The consent sections below are written for both realities.
What Should a Mental Health Intake Form Include?
A complete mental health intake form covers eight sections: identification and contact details, emergency contact and safety, presenting concerns and goals, health and medications, mental health history, family and social context, insurance and payment, and consent. The first six gather clinical and practical information; the last two depend on where you practice, so each gets a full guide below.
Section | What it collects | Why it matters |
|---|---|---|
1. Client information | Names, pronouns, contact details, language, referral source | Identification, respectful address, safe communication channels |
2. Emergency contact & safety | Contact person, safe-to-contact notes | Crisis response without guesswork |
3. Presenting concerns & goals | Reason for seeking counseling, duration, impact, goals | Focuses the first session; screens for risk |
4. Health & medications | Conditions, current medications, sleep, substances | Rules physical contributors in or out; informs referrals |
5. Mental health history | Prior therapy, diagnoses, hospitalizations, self-harm history | Continuity of care; risk context |
6. Family & social context | Household, relationships, work or school, culture, supports | The client’s world outside the session |
7. Insurance & payment | Insurer fields, third-party payers, billing consent | Clean claims; fewer awkward money conversations |
8. Consent & acknowledgements | Privacy, confidentiality limits, e-communication, recording | The legal core: HIPAA acknowledgment in the US, PHIPA/PIPEDA/Loi 25 consent in Canada |
The Complete Intake Form Template
Sections 1–6 follow as copyable field lists; sections 7 (insurance) and 8 (consent) each get a full guide below, because they are the parts that change with your jurisdiction. Copy the fields, or download the fillable PDF and adapt it.
1. Client Information
Legal name · Name you go by · Pronouns (optional)
Date of birth
Address (street, city, state or province, ZIP or postal code)
Phone, and May we leave a voicemail at this number? ☐ Yes ☐ No
Email, and May we email you? (See electronic communication consent, section 8.) ☐ Yes ☐ No
Preferred language for services and documents: ☐ English ☐ Français ☐ Other: ___
Family physician or nurse practitioner (name and clinic, optional)
How did you hear about us?
Accessibility needs or accommodations that would help you participate
2. Emergency Contact and Safety
Emergency contact: name · relationship · phone
Is there anything we should know to contact you safely? (e.g., a shared phone or household, messages you would prefer we not leave)
Worth flagging: the “safe to contact” question quietly protects clients leaving controlling relationships. Keep it even on a short form.
3. Presenting Concerns and Goals
What brings you to counseling now? (a few sentences is plenty)
How long has this been a concern?
Areas of life affected: ☐ Mood ☐ Anxiety or stress ☐ Relationships ☐ Work or school ☐ Sleep ☐ Grief or loss ☐ Trauma ☐ Substance use ☐ Other: ___
In the past month, have you had thoughts of harming yourself or ending your life? ☐ Yes ☐ No ☐ Prefer to discuss in session
What would success in counseling look like for you?
What have you already tried? (previous strategies, self-help, other supports)
Tell clients on the form what a “yes” on the self-harm question means: “we will talk about it together; it does not trigger anything automatic.” List your local crisis line in the form footer. Canadian practices should also list 9-8-8, Canada’s suicide crisis helpline.
4. Health and Medications
Current medical conditions or recent hospitalizations
Current medications (name · dose · prescriber), including psychiatric medications
Past psychiatric medications, if any
Sleep: typical hours and any difficulties
Substance use: alcohol · cannabis · nicotine · caffeine · other (frequency, in the client’s own words)
5. Mental Health History
Previous counseling or therapy (approximate dates, and what helped or didn’t)
Previous diagnoses, as you understand them
Any psychiatric hospitalizations
Any history of self-harm or suicide attempts
Significant losses or experiences you consider traumatic (a yes/no or a short phrase is enough here; you set the pace on what we explore, and when)
6. Family and Social Context
Who is in your household?
Relationship status · children, if any
Work, school, or other daily structure
People or communities you can lean on
Cultural, spiritual, or religious practices you’d like reflected in your care
Family history of mental health concerns (brief)
Worked example (fictional, composite): a completed presenting-concerns section might read: “What brings you now?”: ‘Constant worry since a restructuring at work in March; not sleeping, snapping at my kids.’ Duration: ‘About five months.’ Areas affected: mood, sleep, work. Self-harm: no. Success: ‘Getting through a workday without the dread.’ Four lines, and the first session already has a direction.
Which Insurance Fields Does an Intake Form Need?
If you accept insurance, your form needs the fields that let a claim go through cleanly: the insurer’s name, the member ID and group number, the plan holder’s details when your client is a dependent, and whether the plan covers your license type. Plans reimburse specific credentials, and coverage varies by plan and by state, so ask clients to confirm their benefits before session one.
Insurer: ☐ Aetna ☐ Cigna ☐ UnitedHealthcare ☐ Blue Cross Blue Shield ☐ Anthem ☐ Humana ☐ Optum ☐ Other: ___
Member ID · group number
Plan holder’s full name and date of birth, when your client is a spouse or dependent
Client’s relationship to plan holder: ☐ Self ☐ Spouse ☐ Dependent
Secondary coverage, if any: insurer and numbers (coordination of benefits decides which plan pays first)
Consent to bill the insurer on the client’s behalf, if you submit claims directly
Does your plan cover services by a [your license type]? ☐ Yes ☐ No ☐ Will confirm
If a third party funds the care, an EAP for example, collect the provider’s name, the authorization number, the number of sessions approved, and the authorization end date. If you run a private-pay practice, replace this section with your fee acknowledgment and payment arrangements. Canadian practices bill differently; their insurer fields are in the Canadian section below.
What Consent Language Does an Intake Form Need?
Wherever you practice, the consent block needs the same core pieces: informed consent to collect and use the client’s information, a plain-language statement of confidentiality and its limits, consent to electronic communication, and, if you record sessions or use an AI scribe, a separate express consent for that. In the US, include the privacy-notice acknowledgment HIPAA requires; the exact requirements vary by state and licensing board, so have a lawyer review your final form. Canadian practices need statute-specific consent language instead, which is in the Canadian section below.
The model language below is jurisdiction-neutral. It is a starting point, not legal advice.
Model language for electronic communication:
I consent to receive appointment reminders, documents, and invoices by email at the address above. I understand that ordinary email is not fully secure, and that I may withdraw this consent at any time. My therapist ☐ may ☐ may not leave voicemail at the number above.
Model language for virtual sessions (if applicable):
I consent to sessions by secure video where clinically appropriate. I understand the practical limits of virtual care (technology failures, privacy on my end of the call) and that my therapist will confirm my location at the start of each virtual session in case of emergency.
Model language for session recording and AI-assisted documentation (if applicable):
I consent to my sessions being recorded for documentation purposes. [Tool name] transcribes the session so that my therapist can prepare the clinical note; my therapist reviews every note before it enters my record. Audio is deleted on [schedule]. I may decline or withdraw this consent at any time without affecting my care.
If you use Klarify, an AI assistant for therapists, you can fill those brackets concretely: all Klarify data is stored in Canada, session audio is deleted from storage within 14 days at most, and auto-deletion of audio, transcripts, or entire sessions can run immediately or on a 1-, 7-, 14-, 30-, or 180-day schedule. Klarify is fully HIPAA, PHIPA, PIPEDA, Quebec Loi 25, and GDPR compliant. Whatever tool you use, name it and state its retention behavior. Vague “technology may be used” clauses are not informed consent. Our comparison of therapy note-taking tools covers what to ask vendors.
For Canadian Practices
If you searched for a counselling intake form, this section covers the Canadian specifics. A Canadian intake form must satisfy PHIPA, PIPEDA, or Quebec’s Loi 25 regime, not HIPAA, and it needs insurer fields that US templates leave out. The template sections above apply unchanged; everything below is Canada-specific.
Which Insurance Fields Does a Canadian Intake Form Need?
Most private-practice clients in Canada pay you directly and claim reimbursement through workplace extended health benefits, because provincial plans generally do not cover counseling in private practice. Your form therefore needs the fields that make a claim go through cleanly: insurer name, policy or group number, member ID, the plan member’s details when your client is a dependant, and a note on whether the plan covers your designation.
Field | Where the client finds it | Notes |
|---|---|---|
Insurer: ☐ Sun Life ☐ Manulife ☐ Canada Life ☐ Desjardins Insurance ☐ Green Shield Canada ☐ Blue Cross ☐ Other: ___ | Benefits card or workplace benefits portal | A checkbox list prevents typos that stall claims |
Policy / contract / group number | Benefits card (labeled “policy,” “contract,” or “group”) | Identifies the employer’s plan |
Member ID / certificate number | Benefits card | Identifies the person covered |
Plan member’s full name and date of birth | n/a | Needed when your client is a spouse or dependant on someone else’s plan |
Client’s relationship to plan member | n/a | ☐ Member ☐ Spouse ☐ Dependant |
Secondary coverage? (insurer + numbers) | Second benefits card | Coordination of benefits decides which plan pays first |
Consent to direct billing | n/a | Only if you submit claims on the client’s behalf (e.g., through TELUS Health eClaims or an insurer portal) |
Does your plan reimburse services by a [your designation]? ☐ Yes ☐ No ☐ Will confirm | Client confirms with their insurer | Plans reimburse specific credentials (psychologist, RP, RSW, RCC), and a mismatch means a rejected claim. Ask clients to confirm before session one |
If you see third-party-funded clients, add an optional block for the payer file details:
Payer | Fields to collect |
|---|---|
WSIB (Ontario) or your province’s workers’ compensation board | Claim number · case manager · employer |
ICBC / provincial auto insurer | Claim number · adjuster contact |
Veterans Affairs Canada | VAC file/client number |
NIHB (First Nations and Inuit clients) | Client ID number · prior-approval details, if required |
EAP referral | EAP provider · authorization number · sessions approved · authorization end date |
What Consent Language Does a Canadian Intake Form Need?
A Canadian intake form needs express, informed consent to collect, use, and disclose personal health information under the law that actually governs you: PHIPA in Ontario, PIPEDA federally, or Quebec’s Private Sector Act as amended by Loi 25. HIPAA language does not satisfy any of this. The electronic-communication, virtual-session, and recording consents above work in Canada as written; the two blocks below are the statute-specific pieces.
The model language below is a starting point, not legal advice. Have your college’s practice advisory service or a lawyer review your final form, and fill the bracketed choices for your province.
Model language for the collection and use of personal health information:
I understand that [Practice Name] collects my personal information and personal health information to provide counselling services, communicate with me, keep records required by [regulatory college], and process payment. My information is collected, used, and disclosed in accordance with [PHIPA / PIPEDA / Quebec’s Act respecting the protection of personal information in the private sector], is not shared without my express consent except as required or permitted by law, and I may withdraw my consent, or request access to or correction of my record, at any time.
Model language for the limits of confidentiality:
What I share in counselling is confidential, with exceptions my therapist has explained to me: where there is a risk of serious harm to me or to another person; where information suggests a child is in need of protection; where a court orders disclosure or another law requires it; and where my therapist’s regulatory college requires information for quality assurance or an investigation. Where disclosure is required, my therapist shares only the minimum necessary.
How Do Consent and Privacy Rules Differ by Province?
The biggest differences are which statute governs a private practice, how old a client must be to consent alone, and what the province restricts you from collecting. Every province and territory has mandatory child-protection reporting, and Canadian courts recognize a public-safety exception to confidentiality (Smith v. Jones, 1999 SCC). But the details below change what your form should say.
Province | Privacy law for a private practice | What it changes on your intake form |
|---|---|---|
Ontario | PHIPA (health information custodians); PIPEDA for non-health commercial information | Knowledge-based consent: your form must show the client knew the purposes. Health numbers are restricted (PHIPA s. 34): do not collect OHIP numbers unless you bill OHIP. Consent to treatment is capacity-based with no minimum age. Ontario also mandates reporting sexual abuse of a patient by a regulated health professional (Regulated Health Professions Act, 1991) |
Quebec | Private Sector Act (P-39.1), as amended by Loi 25 | Consent must be clear, free, informed, and given for specific purposes (s. 14); collect only what is necessary (s. 5); designate a person in charge of protecting personal information (in a solo practice, that is you, named on your privacy notice). Minors 14+ may generally consent alone to care (Civil Code, art. 14). Offer the form in French |
British Columbia | PIPA (BC) for private practices | The Infants Act, s. 17 lets a capable minor consent on their own once you are satisfied they understand the care’s nature, consequences, benefits, and risks, and that it is in their best interests. Build your minor-consent section around capacity, not age |
Alberta | PIPA (Alberta) for most private practices; the Health Information Act applies to designated custodians | Confirm which statute applies to your registration before finalizing your privacy notice, because the consent and access rules differ |
Saskatchewan · Manitoba | HIPA (SK) · PHIA (MB) | These statutes bind “trustees”; whether a private counselling practice is covered varies by profession and setting. Where they don’t apply, PIPEDA does |
Atlantic Canada | PHIA (NS) · PHIPAA (NB) · Health Information Act (PEI) · PHIA (NL) | Health-information statutes with custodian duties similar in spirit to PHIPA. Check whether your practice is a covered custodian |
Territories, and anywhere no provincial law applies | PIPEDA’s consent and limiting-collection principles (Schedule 1) are the floor for the model language above |
Retention rules also differ by college, not just by province. CRPO requires registrants to “retain the record for at least 10 years from the date of the last interaction with the client, or for 10 years from the client’s 18th birthday, whichever is later” (CRPO Professional Practice Standard 5.1). OPQ and other colleges set their own periods, so check your college’s current standard rather than assuming Ontario’s.
What Should You Not Collect on an Intake Form?
Collect only what you need to begin care. Every extra field is something you must protect, retain, and one day securely destroy. In Canada, Quebec’s necessity rule (Private Sector Act, s. 5) and PIPEDA’s limiting-collection principle make that restraint a legal duty; in the US, the same restraint is good risk management under any state’s rules. These are the fields to leave off, and what to do instead. The first two rows name Canadian identifiers; treat their US counterparts, like the Social Security Number, with the same restraint.
Don’t collect | Why | Instead |
|---|---|---|
Social Insurance Number | Never needed for counseling; maximum identity-theft value | Nothing. No substitute is needed |
Provincial health-card numbers (OHIP, RAMQ, MSP…) | Ontario restricts health-number collection and use (PHIPA s. 34); other provinces restrict health-card use too. Private counseling doesn’t bill the provincial plan | Leave it off unless you genuinely bill the provincial plan |
Full credit-card numbers on a paper or PDF form | A stored card number on an intake form is a breach waiting to happen | Collect payment details through your payment processor at booking |
Detailed trauma narratives | Forms get skimmed and stored; the narrative belongs in session, at the client’s pace | A yes/no plus “anything you want me to know before we start” |
Immigration status, criminal record, exact income | Rarely necessary for care; heavy data with real consequences if breached | For sliding scale, ask “would our reduced-rate options be helpful?” No income figure is required |
Scored questionnaires before consent is signed | Administering and scoring instruments is a clinical act; consent comes first | Administer measures like the PHQ-9 after consent, in or after the first session |
How to Use This Intake Form in Your Practice
Send the form two or three days ahead through a secure channel, review it in the first ten minutes of the intake session, and let it point the conversation rather than replace it. The form gathers; the session explores. Store the completed form in the clinical record, and review the template itself once a year. Insurers, statutes, and your own services all drift.
Three habits that make the form earn its keep:
Read it before the client arrives, not with them. Flag the risk question, the medication list, and the “safe to contact” answer. Those three lines shape your first session, and your mental status exam cheat sheet observations, more than anything else on the form.
Say out loud what the form said. “You mentioned the worry started around a restructuring in March. Should we start there?” Clients notice when the paperwork was actually read.
After intake, close the loop into ongoing documentation. The intake form feeds the first note; from session two onward, a consistent format like our DAP notes template keeps the chart coherent.
Frequently Asked Questions
What is a client intake form in therapy?
A client intake form is the document a new client completes before or at their first session. It collects identification and contact details, presenting concerns, health and mental health history, insurance information, and the written consents your regulator and privacy law require. It gives the therapist a clinical head start and creates the legal record that consent was informed.
Can I use a US intake form template in a Canadian practice?
Not as-is. US templates reference HIPAA, US insurers, and US credentials, none of which govern or apply in Canada. A Canadian intake form needs consent language that reflects PHIPA (Ontario), PIPEDA (federal), or Quebec’s Loi 25 regime, insurer fields for plans like Sun Life, Manulife, Desjardins, and Green Shield Canada, and Canadian spelling and credentials throughout.
Can I email intake forms to clients?
Yes, if the client has consented and you take reasonable safeguards. Ordinary email is not fully secure, so tell clients that plainly, get their consent to use it in writing, and prefer a secure portal or encrypted delivery for completed forms. Document the consent on the form itself so the choice is on record.
Does a minor need a parent to sign the intake form?
It depends on where you practice. In the US, the rules vary by state and licensing board, so check both before your first session with a minor. In Canada, it depends on the province: in Quebec, a minor 14 or over may generally consent alone to care required by their state of health; in BC, the Infants Act lets a capable minor consent on their own once the provider is satisfied they understand the care and it is in their best interests; and Ontario has no minimum age at all, since consent there is capacity-based. Check your regulator’s guidance for your setting.
Do I need separate consent for recording sessions or using an AI scribe?
Yes. Recording and AI-assisted documentation need express, informed, and revocable consent. A general privacy clause is not enough. Name the tool, say what is captured, where the output is stored, how long audio is kept, and make clear the client can decline or withdraw at any time without affecting their care.
Klarify writes your intake session notes for you. Record the intake, and Klarify drafts the note in your format (or in a custom intake template you build once) while Klara helps fill intake forms, referral letters, and treatment plans. Every therapist on Klarify also gets a free Psychology Today-style public profile hosted on klarify.ca, with built-in marketing features for attracting clients. The first session should be about the client, not the clipboard.
Sources
Personal Health Information Protection Act, 2004, S.O. 2004, c. 3, Sched. A (Ontario) · ontario.ca/laws/statute/04p03
Personal Information Protection and Electronic Documents Act, S.C. 2000, c. 5, Schedule 1 · laws-lois.justice.gc.ca
Act respecting the protection of personal information in the private sector, CQLR c. P-39.1, as amended by Loi 25 (Quebec) · legisquebec.gouv.qc.ca
Civil Code of Québec, CQLR c. CCQ-1991, art. 14 · legisquebec.gouv.qc.ca
Infants Act, R.S.B.C. 1996, c. 223, s. 17 (British Columbia) · bclaws.gov.bc.ca
Regulated Health Professions Act, 1991, S.O. 1991, c. 18 (Ontario) · canlii.org
CRPO, Professional Practice Standard 5.1: Clinical Records · crpo.ca
Smith v. Jones, [1999] 1 S.C.R. 455 · canlii.org
Regulatory references last reviewed 18 August 2026. This page is practice guidance, not legal advice. Confirm requirements with your college and, where needed, legal counsel.