Formfy

Therapy Informed Consent Form

Builder

Therapy Informed Consent Form

Which intake form are you building?

Start from a recommended template that fits your needs. You can customize everything later.

Psychotherapy Intake Form

We kindly ask your cooperation in answering the questions below as accurately as possible since they will assist your counselor in assessing your needs pre-appointment.

Section 1: Demographics & contact information

Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Cell Phone Number
(000) 000-0000
Please enter a valid phone number.
Home Phone Number
(000) 000-0000
Please enter a valid phone number.
Email
example@example.com
Gender
Please Select▾
Age
ex: 23
Birth Date
MM-DD-YYYY▦
Date
Preferred contact method
PhoneEmailText

Section 2: Emergency contacts & safety

Emergency contact name
Relationship
Emergency contact phone
(000) 000-0000
Please enter a valid phone number.
Would you like to share more about your current wellbeing and safety?
NoYes
If yes, please share what you would like us to know
Are you currently experiencing a crisis or thoughts of harm?
NoYes

Section 3: Safety assessment

In the past two weeks, have you had thoughts of self-harm?
NoA littleOften
Have you ever attempted suicide?
NoYes
Are you currently having thoughts of harming yourself or others?
NoYes
Recent thoughts of suicide or self-harm — please describe

Section 4: Medical & mental health history

Current medical conditions
Past mental health diagnoses
Current medications
Allergies

Section 5: Trauma history

Have you experienced any of the following? (check all that apply)
Physical abuseEmotional abuseSexual abuseNeglectDomestic violenceCommunity violenceSerious accident or injurySudden loss of a loved oneNone of the abovePrefer not to say
Approximate age(s) when this occurred
Have you ever received support or therapy related to these experiences?
YesNo
How do these experiences affect you today?

Section 6: Family & social history

Family mental health history
Relationship / marital status
Living situation
Social support
Were you adopted?
YesNo
Where did you grow up?
List your siblings and their ages
Did your parents divorce?
YesNo

Section 7: Current concerns

What brings you in today?
How long has this been present?

Section 8: Goals for therapy

What are your goals for therapy?
What would a successful outcome look like for you?
Which goal feels most important to start with?

Section 9: Substance use history

Substance use history
Frequency of use
Do you exercise regularly?
YesNo
How much time each day do you exercise?
Have you ever tried any of the following? (check all that apply)
MethamphetamineCocaineStimulants (pills)HeroinLSD or hallucinogensMarijuanaPain killers (not as prescribed)MethadoneTranquilizers / sleeping pillsAlcoholEcstasyOther
Have you ever smoked cigarettes?
YesNo
If yes, how many packs per day?
For how many years?
Other behavioral health information

Section 10: Treatment history & medications

Previous treatment or therapy
Current providers
Current medications
Notes

Section 11: Past psychiatric medications

If you have ever taken any of the following medications, please indicate the dates and daily dosage.

Psychiatric medications you have ever taken
Have you ever taken it?DatesDosageSide Effects?
Prozac (fluoxetine)
Zoloft (sertraline)
Luvox (fluvoxamine)
Paxil (paroxetine)
Celexa (citalopram)
Lexapro (escitalopram)
Effexor (venlafaxine)
Cymbalta (duloxetine)
Wellbutrin (bupropion)
Remeron (mirtazapine)
Serzone (nefazodone)
Anafranil (clomipramine)
Pamelor (nortriptyline)
Tofranil (imipramine)
Elavil (amitriptyline)
Tegretol (carbamazepine)
Lithium
Depakote (valproate)
Lamictal (lamotrigine)
Topamax (topiramate)
Seroquel (quetiapine)
Zyprexa (olanzapine)
Geodon (ziprasidone)
Abilify (aripiprazole)
Clozaril (clozapine)
Haldol (haloperidol)
Prolixin (fluphenazine)
Risperdal (risperidone)
Ambien (zolpidem)
Sonata (zaleplon)
Rozerem (ramelteon)
Restoril (temazepam)
Desyrel (trazodone)
Adderall (amphetamine)
Concerta (methylphenidate)
Ritalin (methylphenidate)
Strattera (atomoxetine)
Xanax (alprazolam)
Ativan (lorazepam)
Klonopin (clonazepam)
Valium (diazepam)
Tranxene (clorazepate)
Buspar (buspirone)
Other medications?

Section 12: Primary care physician

Primary care physician name
Clinic or practice name
Phone Number
(000) 000-0000
Please enter a valid phone number.
May we contact your primary care physician about your care?
YesNo

Section 13: Relationship

What is your relationship status?
MarriedSeparatedWidowedOtherNever MarriedDomestic Partnership
How would you rate your relationship well-being?
12345678910
Not functioningNo problems

Section 14: Employment

What is your employment status?
EmployedRetiredDisabledHomemakerOtherUnemployedSelf-employedStudent
Your average monthly income (USD)
ex: 23
USD

Section 15: Family & household

Including yourself, how many people live in your household?
−1+
Total household monthly income (USD)
ex: 23
USD
Family history of any of the following conditions (check all that apply)
YesNoIndicate Family Member
Anxiety
Depression
Substance abuse / alcohol
Arrests
Obesity
Schizophrenia
Suicide attempt
Domestic violence
Additional comments
How would you rate your family relationship?
12345678910
Not functioningNo problems

Section 16: History

Have you previously received any type of mental health services?
YesNo
If yes, please describe the services you received
Are you currently on psychiatric medication?
YesNo

Section 17: General health information

How would you rate your physical health condition?
12345678910
Very PoorExcellent
How often do you exercise?
12345678910
NoneVery Often
How would you describe your general appetite?
12345678910
Very PoorVery Hungry
How would you describe your stress level throughout the day?
12345678910
Very RelaxedVery Stressed
How would you rate your general happiness and well-being?
12345678910
Very unhappyVery happy

Section 18: Symptoms

Please answer all of the statements below that describe your concerns

I often experience
Fear of many thingsGuiltPanic attacksAvoiding peopleHaving nightmaresAnxiety, nervousnessDiscomfort in social situationsSexual issuesOther
I often have
Suicidal thoughtsMemory problemsSleeping disorderStruggled to explain myself to othersObsessive thoughtsViolent thoughtsStress and tensionMedical concernsFatigueWork problemsOther
I often feel
LonelyEmptySadHopeless about the futureExcessive guiltSuspiciousOther

Section 19: Referral source

How did you hear about us?
Doctor or provider referralFriend or familyInsurance directoryOnline searchSocial mediaOther
Referred by (name, if applicable)
Reason for referral (if applicable)

Section 20: Appointment & availability

Please check your available times for a weekly appointment? (Check as many as applies)
MondayTuesdayWednesdayThursdayFriday
9:00 AM - 10:00 AM
10:00 AM - 11:00 AM
11:00 AM - 12:00 PM
1:00 PM - 2:00 PM
2:00 PM - 3:00 PM
3:00 PM - 4:00 PM
4:00 PM - 5:00 PM
Please book an available time for your first appointment?
06/29/2026▦
9:00 AM - 10:00 AM10:00 AM - 11:00 AM11:00 AM - 12:00 PM1:00 PM - 2:00 PM2:00 PM - 3:00 PM3:00 PM - 4:00 PM4:00 PM - 5:00 PM

Section 21: Insurance status

Do you have insurance?
YesNo

Section 22: Consent, notices & policies

I acknowledge the consent, notices, and office policies provided.
I acknowledge
Signature
Your signature
✕
Printed name
Date signed
MM-DD-YYYY▦
Guardian signature (if under age 18)
Your signature
✕
Guardian printed name
Relationship to patient (if applicable)
Submit

A therapy informed consent form documents that the client understands what therapy involves before it begins: the nature of the work, its benefits and limits, your policies on fees, cancellations and communication, and how records are handled - concluded with a dated signature.

Use the builder above to assemble yours in minutes: pick a starting template, keep the sections you need, add your own questions, and download a print-ready PDF or send it digitally for e-signature.

What belongs in a therapy informed consent form

  • Nature of therapy — what sessions involve, the approach used, and what therapy can and cannot promise
  • Risks and benefits — honest framing: discomfort can precede progress
  • Limits of what stays in the room — the specific situations where a therapist must act, stated plainly
  • Fees and billing — session rates, accepted payment, and what happens with unpaid balances
  • Cancellation policy — the notice window and the fee for missed sessions
  • Communication policy — how to reach you between sessions and expected response times
  • Emergencies — what to do in a crisis, with 988 and 911 stated explicitly
  • Records — how session records are kept and how a client can request theirs
  • Client acknowledgment — a statement of understanding, signature, printed name, and auto-filled date

Writing consent language clients actually read

  • Short sections with headings — a wall of legal text gets signed unread; headed sections get skimmed and understood
  • First person where possible — “I understand that…” reads as agreement, not fine print
  • Concrete numbers — “24 hours notice, $75 missed-session fee” beats “reasonable notice, applicable fees”
  • One acknowledgment per idea — separate checkboxes for policies, fees, and emergencies instead of one catch-all
  • A real signature moment — signature, printed name, and date at the end, not buried mid-form

Collect signed consent before the first session

Send the consent form digitally with the intake: the client reads it at home, checks each acknowledgment, signs on their phone, and the dated PDF is in your records before session one. Clients who prefer paper get the identical printed version. Every consent is signed, dated, and filed the same way.

Frequently asked questions

›What is a therapy informed consent form?

A document the client signs before starting therapy confirming they understand what therapy involves, its limits, your policies on fees and cancellations, how records are handled, and what to do in an emergency.

›What policies should the consent form state?

At minimum: session fees and billing, the cancellation window and missed-session fee, how to reach you between sessions, emergency instructions with crisis numbers, and how records are kept and requested.

›Is an electronically signed consent form valid?

E-signatures are widely used for therapy consent. The form captures a drawn or typed signature with an automatically dated signing line, and you receive the signed PDF for your records. For requirements specific to your jurisdiction, check your licensing board’s guidance.

›Can I edit the consent language?

Yes - every clause is editable. Keep the structure, replace the wording with your own policies, add clauses, and set which acknowledgments are required.

›Should consent be a separate form or part of the intake?

Either works. Many practices combine them: the intake collects history and the final section carries consent with the signature. The builder supports both patterns.

›How do minors sign consent?

For clients under 18, the form automatically collects a parent or guardian signature alongside the minor’s details.

›What does it cost?

Free to build and preview; $14.99 one-time for the print-ready PDF or a single digital send; plans from $19 per month for unlimited clients.