client intake form template counselling

Professional Counseling Services Intake & Consent Form

Instructions for Use

• Complete all sections of this form accurately to ensure your counselor has the necessary background to provide effective support.
• Review the terms of service carefully, as this document establishes the professional boundaries and financial obligations of the engagement.
• Ensure both the client and the authorized representative (if applicable) sign and date the document before the initial session commences.

Parties & Definitions

This Intake Form ("Agreement") is entered into by and between [Counselor/Practice Name], located at [Practice Address] ("Provider"), and [Client Full Legal Name], residing at [Client Residential Address] ("Client").

Operative Clauses

1. Scope of Services: The Provider agrees to provide professional counseling services to the Client. The Client understands that counseling is a collaborative process and that the effectiveness of the treatment depends on the Client’s active participation.

2. Fees and Payment: The Client agrees to pay the rate of [Currency Amount] per [Session Duration] session. Payment is due at the time of service. Accepted payment methods include: [ ] Credit Card, [ ] Electronic Transfer, [ ] Check, [ ] Other: [__________].

3. Cancellation Policy: The Client must provide at least [Number] hours of notice for any appointment cancellation. Failure to provide such notice will result in a late cancellation fee of [Currency Amount], which is not covered by insurance.

4. Confidentiality: All information shared during sessions is confidential, subject to the following legal exceptions: a) Disclosure is required by law (e.g., court order). b) Risk of harm to self or others. c) Reports of abuse or neglect of children, elderly, or vulnerable persons. d) Insurance billing requirements (if applicable).

5. Communication: Routine communication regarding scheduling should be directed to [Contact Email Address or Phone Number]. The Client acknowledges that electronic communication may not be fully secure.

6. Termination: Either party may terminate this professional relationship at any time. The Client is encouraged to discuss the decision to terminate with the Provider to ensure a proper transition or referral.

7. Emergency Protocol: In the event of a mental health emergency, the Client agrees to contact [Emergency Services Number/Local Crisis Hotline] or proceed to the nearest emergency department.

Signature & Acknowledgment

By signing below, I acknowledge that I have read, understood, and agreed to the terms outlined above.

Client Signature: __________ Printed Name: [Full Legal Name] Date: [__________]

Provider Signature: __________ Printed Name: [Provider Name] Title: [Professional Title/License Number] Date: [__________]

Legal Disclaimer: This document is a general framework and does not constitute formal legal advice. Counseling practices are subject to specific state and regional regulations; please consult with qualified legal counsel to ensure compliance with local statutes and professional licensing board requirements.