TEMPLATE FOR THERAPISTS
Individual Therapy Intake Questionnaire
Most intake forms ask about symptoms. This one asks about the whole person—their identity, their worldview, their relationships with food, faith, and body, and what they actually need from therapy. It's the first message you send about the kind of practice you run.
This template was built from years of real intake work—first as a solo clinician, then scaling into group practice. What I kept running into was the same problem: generic intake forms that collected data but didn't actually help me understand who was sitting across from me. I needed something that asked about culture and identity before session one. That named trauma without making it a clinical interrogation. That asked about spirituality—because worldview shapes everything. How a client understands their suffering. Whether they trust a diagnosis. Why they're here at all. So I built it. And now it's yours.
This questionnaire goes where most intake forms don't. It includes a complementary and integrative health section—covering supplements, herbal remedies, acupuncture, traditional medicine, energy work, and more—because these practices are clinically relevant and clients rarely mention them unless asked. It includes a spirituality and worldview section that asks directly how faith or belief shapes a client's relationship to mental health, help-seeking, and diagnosis. And it includes a full trauma screen, a tiered safety section, and a cultural identity section that treats who someone is as central to the work—not background noise. It's also warm. Questions are written to feel like an opening conversation, not a clinical checklist. Because the intake form is part of the therapeutic relationship—and that relationship starts before session one.You're tired of generic intake forms that collect data but don't help you understand who's actually in the room—and especially if any of these sound familiar:
You want to ask about culture, identity, and spiritual worldview before session one—not wait for it to come up
Your clients use supplements, herbal remedies, acupuncture, or traditional healing practices, and you want that on the record
You need a safety screen that's thorough but doesn't feel cold or interrogatory
You're scaling from solo to group practice and need intake documentation that works across a team
You want something your clients can complete thoughtfully and return before the first session
You believe the intake form is part of the therapeutic relationship—and you want it to reflect that
You need something you can customize to your voice, your population, and your practice—not something designed for everyone, which usually means designed for no one
1. Download and open—The template is a .docx file. Open it in Microsoft Word or Google Docs.
2. Replace the red brackets—Every [BRACKETED FIELD] in red is a placeholder. Swap them out with your practice name, contact information, and any practice-specific language before sharing with clients.
3. Review the teal notes—Throughout the document, teal clinician notes explain the purpose of each section and flag decisions to make—which sections to keep, adapt, or remove. Delete all notes before finalizing.
4. Make it sound like you—Questions are written in a warm, inviting register designed to feel like a conversation. Adjust the language to match your voice and your client population.
5. Upload to your EHR or send directly—The finished form is ready to copy into your EHR's intake form builder, share as a PDF, or send via your client portal.
6. Have it reviewed—This template is designed for adaptation, not verbatim use. Before distributing to clients, have your final version reviewed by your licensing board, malpractice carrier, and/or a licensed attorney. Requirements vary by state.
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