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Client Intake Forms

Please complete all required fields carefully. Your information is strictly confidential and protected under HIPAA regulations. A clinician will review your submission and contact you within 24 hours.

Personal Info

Health History

Consent & Submit

Personal Information

Basic contact and demographic details.

First Name * Please enter your first name.

Last Name * Please enter your last name.

Date of Birth * Date of birth is required.

Phone Number * Please enter a valid phone number.

Email Address * Please enter a valid email address.

Mailing Address

Health & Treatment History

Help us understand your background so we can match you with the right support.

Primary Reason for Seeking Therapy *

Anxiety / Stress Depression / Mood Trauma / PTSD Relationship / Family Grief / Loss Other

Please select at least one reason.

Please describe your current concerns or goals for therapy:

Have you had therapy before?

Current Medications (if any)

Preferred Session Format *

Video Call Phone Call In-Person Flexible / Open

Please select a session format.

Insurance Provider / Self-Pay

Our billing coordinator will verify coverage after submission.

Consent & Acknowledgments

Please review and acknowledge the following before submitting.

HIPAA Privacy Notice

In Therapy complies with the Health Insurance Portability and Accountability Act (HIPAA). All information provided is confidential and will only be used for treatment, payment, and healthcare operations. You have the right to access, amend, or request restriction of your records.

Treatment Consent

By submitting this form, I consent to receive psychological evaluation and/or therapy services from In Therapy. I understand the nature of treatment, potential risks/benefits, and that I may withdraw consent at any time.

I have read and acknowledge the HIPAA Privacy Notice * You must acknowledge the privacy notice.

I consent to treatment and understand my rights * You must provide consent to proceed.

Type Your Full Name as Signature * Signature is required.

Date * Date is required.

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Forms Submitted Successfully

Thank you for taking this important step. Our clinical team will review your intake information and reach out to you within 24 business hours to schedule your initial session.