intake form template for counseling

Client Counseling Intake and Service Agreement

Instructions for Use

• Complete all sections in brackets with accurate information before the initial session.
• Provide a copy of this document to the client and retain the original in the secure client record file.
• Review all terms with the client to ensure mutual understanding of professional boundaries and service expectations.

Parties & Definitions

This Agreement is entered into by and between [Counselor/Practice Name], hereafter referred to as the "Provider," and [Client Full Legal Name], hereafter referred to as the "Client."

Client Contact Information: Address: [] Phone: [] Email: [] Emergency Contact: [] (Relationship: [__________])

Operative Clauses

1. Scope of Services: The Provider agrees to offer counseling services focused on [__________]. The Client acknowledges that these services are not intended for crisis intervention or emergency mental health support.

2. Fees and Payment: The Client agrees to pay a fee of [] per [session/hour]. Payment is due at the time of service via [Cash/Check/Credit/Electronic Transfer]. Cancellations must be made at least [] hours in advance to avoid a late fee of [__________].

3. Confidentiality: All information disclosed during sessions is strictly confidential, except where disclosure is required by law. Mandatory reporting requirements include:

   • Reasonable suspicion of child or elder abuse.
   • Threats of bodily harm to self or others.
   • Court orders or legal subpoenas.

4. Termination of Services: Either party may terminate this agreement at any time with written notice. The Provider reserves the right to terminate services if the Client fails to comply with payment policies or if the Provider determines the Client's needs exceed the scope of the Provider's expertise.

5. Communication Policy: Non-emergency communication via email or text is permitted for scheduling purposes only. The Provider will generally respond within [__________] business days.

6. Informed Consent: The Client acknowledges that they have been informed of the risks and benefits of counseling and voluntarily consents to participate in the process.

Signature & Acknowledgment

By signing below, the Client acknowledges that they have read, understood, and agreed to the terms outlined in this document.

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

Provider Signature: __________ Printed Name: [] Title: [] Date: [__________]

Legal Disclaimer: This document is a general framework and does not constitute legal advice. Please consult with qualified legal counsel to ensure compliance with your specific jurisdiction's licensing board requirements and state privacy laws.