intake form sample for therapy

Professional Therapy Services Intake and Consent Form

Instructions for Use

• Complete all sections of this form accurately to ensure your provider has the necessary background and legal authorization to begin treatment.
• Review the operative clauses carefully; by signing, you acknowledge your understanding of the financial and clinical policies outlined herein.
• Submit the signed original to your provider’s office prior to your initial session to avoid delays in service commencement.

Parties and Definitions

This Intake and Consent Form ("Agreement") is entered into by and between: Provider: [Provider/Practice Name], located at [Practice Address] ("Provider"). Client: [Full Legal Name], residing at [Client Home Address] ("Client"). Emergency Contact: [Contact Name], reachable at [Phone Number] ("Emergency Contact").

Operative Clauses

1. Scope of Services: The Provider agrees to furnish psychotherapy or counseling services to the Client. The Client understands that therapy is a collaborative process and that progress is dependent upon the Client’s active participation.

2. Confidentiality: All information shared during sessions is confidential and protected by law, except in the following circumstances:

   • Risk of harm to self or others.
   • Reasonable suspicion of abuse or neglect of a child, elder, or dependent adult.
   • Court order or legal subpoena.
   • Other: [__________].

3. Financial Responsibility: The Client agrees to pay the fee of [Fee Amount] per [Session Duration] session. Payment is due at the time of service.

   • Payment via Insurance (Policy #: [__________])
   • Private Pay (Credit Card/Check/Cash)

4. Cancellation Policy: The Client must provide [Number] hours of notice for any cancellation. Failure to provide sufficient notice will result in a late cancellation fee of [Fee Amount], which is not covered by insurance.

5. Communication: The Client acknowledges that electronic communication (email/text) may not be secure. The Provider’s policy on digital communication is: [__________].

6. Termination of Services: Either party may terminate this Agreement at any time. The Provider reserves the right to terminate services if the Client is non-compliant with treatment goals or if the Provider determines the Client’s needs fall outside their scope of practice.

7. Emergency Protocol: In the event of a mental health crisis, the Client is instructed to contact [Emergency Service Name/Number] or proceed to the nearest emergency room.

Signature and Acknowledgment

By signing below, I acknowledge that I have read, understood, and agreed to the terms outlined in this document. I consent to receive professional services from the Provider.

Signature: __________ Printed Name: [Full Legal Name] Title: [Client or Legal Guardian] Date: [Date]

Legal Disclaimer: This document is a general framework for informational purposes only and does not constitute legal advice. You must consult with qualified legal counsel in your specific jurisdiction to ensure compliance with local, state, and federal laws, including HIPAA and professional licensing board regulations.