intake form template for therapy

Client Registration and Clinical Consent Form

Instructions for Use

• Please complete all sections of this document in full prior to your initial session.
• Ensure that all contact and emergency information is current and accurate to facilitate clear communication.
• Retain a copy of this document for your personal records once signed and dated.

Parties and Definitions

This agreement is made between [Provider/Practice Name] ("Provider") and [Client Full Legal Name] ("Client").

Client Information: Full Name: [] Date of Birth: [] Address: [] Phone Number: [] Email: [__________]

Emergency Contact: Name: [] Relationship: [] Phone: [__________]

Operative Clauses

1. Nature of Services: The Client acknowledges that therapy is a collaborative process and that progress depends on the Client's active participation. The Provider agrees to deliver clinical services in accordance with professional standards and ethical guidelines.

2. Confidentiality: All information disclosed in sessions is confidential, except as required by law. Exceptions include, but are not limited to: (a) suspicion of abuse or neglect of a child or vulnerable adult; (b) clear and immediate threat of harm to self or others; or (c) court order or legal subpoena.

3. Fees and Payment: The Client agrees to pay [Amount] per session. Payment is due at the time of service via [Payment Method]. Cancellations must be made at least [Number] hours in advance, or the Client may be charged a fee of [Amount].

4. Communication: Email and text messaging are for scheduling and administrative purposes only. Clinical content should be reserved for in-person or telehealth sessions. The Provider does not guarantee the security of electronic communications.

5. Termination: Either party may terminate the professional relationship at any time. The Provider reserves the right to terminate services if the Client fails to comply with payment policies or if the Provider determines that the Client’s needs exceed the Provider’s scope of practice.

6. Insurance and Billing: [ ] I will be using insurance. (Insurance Provider: [__________]) [ ] I will be paying out-of-pocket (Self-Pay).

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: [] Title: [Client / Guardian] Date: []

Legal Disclaimer: This document is a general framework and does not constitute formal legal advice. Consult with qualified legal counsel to ensure compliance with specific state regulations, health privacy laws (such as HIPAA), and professional board requirements in your jurisdiction.