A counseling intake form is used by counselors to collect the data and personal information of their clients. The form is accompanied by other documents such as informed consent forms and even contract agreements. This form must be completed by the client before he will proceed to meet the counselor during their scheduled counseling sessions.
Counseling Intake Form in DOC
How to Create a Counseling Intake Form
Every counselor can create his own intake form as long as he knows what details he will need to acquire from his clients. With the steps below, a counselor can have an effective and complete counseling intake form.
Step 1: Start with the header.
Indicate the title of the form along with a confidentiality agreement statement. Some counselors will include their names and logos above the form’s title to introduce themselves to the client. Additionally, the confidentiality agreement statement will inform and assure the client that his details will be kept and used only for the purpose of the counseling sessions, as well as not to be disclosed to outside parties without his consent.
Step 2: Add a section for the client’s general information.
This section must cater the client’s full legal name, age, birth date, address, contact numbers, and even the client’s employer. The client’s insurance company can also be included as part of this section to identify the organization who will be shouldering or sponsoring the client’s payments.
Step 3: Incorporate an area for detailing the problem of the client.
A blank space can be allotted for the problem description. On the other hand, questions can also be listed to assure that the client will be disclosing relevant information about his concerns.
Step 4: Indicate a client history section.
This refers to the family and medical history of the client. The purpose of gathering this information is to determine the beginning or the instance when the concerns of the client have bloomed and affected the client’s daily living. Other counselors also demand the disclosure of the client’s educational and job history to obtain data about how the client can be managed and what activities will be beneficial for the client’s improvement.
Step 5: Place an acknowledgment statement.
This is the last step wherein the client will be able to know his obligations and responsibilities. To complete the form, the client must affix his signature along with the date of when the document was filled out and submitted to the counseling center.
Once the intake form is submitted by the client, the staff of the counseling center must address the form and information to the counselor. A duplicate copy should also be kept by the center or organization to assure that every client-counselor transaction is recorded appropriately.
Confidential Adult Counseling Intake Form
Types of Counseling Intake Forms
There are three common types of counseling intake forms that are used and customized by counselors nowadays. The first type is the general counseling intake form which is the most common among the three. This contains the details of the client and a few information that will be beneficial for constructing a counseling session plan. Second is a pre-counseling intake form that is usually used by authorities or government agencies for their complainants. The form will have the client’s contact information, the discrimination information, desired resolution, as well as the identification of the complainant’s counselor. Lastly, a counseling application intake form is used by some organizations who require their clients to become members of the group before any counseling session will be conducted. The form will indicate the appointment availability of the client and the client’s payment option along with other necessary details such as statuses and the client’s histories.
Counseling Application Intake Form
Pre-Counseling Intake Form
Examples of Counseling Intake Forms
The examples described below are grouped and categorized based on its relativity and the target users of the form. Scholastic, family, legal, and personal counseling intake forms are the four categories:
Scholastic counseling intake documents are intake forms that are used by students for their educational and career issues:
Academic Counseling Intake Form
Career Counseling Intake Form
Academic Counseling Intake Form – This form is handed out by an academic adviser who counsels students in order for them to decide what course or field in the industry they want to focus on with their studies. The form is composed of three pages wherein the primary page is allotted for the student information section. This is where the student or the client of the adviser will state his name, student identification number, and his nickname or other names that he prefers to be called as an alias. The second page of the form contains a questionnaire where the student will have to disclose his reasons why he is in need of the academic adviser’s counseling sessions. This page also indicates the academic progress and the medical status of the student that needs to be taken into consideration by the adviser before any activity will be mandated as part of the scheduled sessions. Lastly, the third page contains checklist items that the student must mark to inform the adviser about his personal concerns such as evident anxiety breakouts, insomnia, relationship problems, and all sorts of abuse that the student has acquired in his current state.
Career Counseling Intake Form – Along with an academic adviser, career counselors also do counseling sessions to help students and individuals who want to have a clear view of where they are heading and what profession they must take to achieve their personal successes. The form is a two-page document that gathers the student’s education information, employment information, military history, and activity details. The data stated on the form will aid in determining the suitable career for the student as well as the possible barriers that the student will be facing. It is significant that the student will enlist his strengths and weaknesses on the form as well to allow the counselor in advising an action plan addressing the weaknesses and maximizing the strengths of the student to solve issues that will arise in the student’s path to reaching his dream career.
Family-related counseling intake forms are used by the members of a household and the court. Parenting, child custody, and marital counseling intake forms are some of the example documents that are grouped for this form category:
Child Custody Recommending Counseling Intake Form
Co-Parenting Counseling Intake Form
Discernment Counseling Intake Form
Family Counseling Intake Form
Marital Counseling Intake Form
Premarital Counseling Intake Form
Family Counseling Intake Form – Improving the interaction, connection, cooperation, and the relationship of a family is the role of a family counselor. With an eight-page family counseling intake form, the counselor can obtain the details of the client’s history that relate to the problems he is dealing with his family. The general information of the client, health history, and a set of questions complete the primary pages of the form. To secure that the client approved and agreed with the intention of the counselor to use his details, the client must read and sign the informed consent section of the form along with the therapy contract agreement, and an acknowledgment receipt.
Premarital Counseling Intake Form – Determining the couple’s roles after the wedding ceremony is the reason why this form serves a great use to any marital counselor. With the premarital counseling intake form, both partners who plan to get into a marriage union will be able to disclose their personal information and their medical and mental health history. An alcohol or substance survey questionnaire is also included on the form to be answered by the couple along with their own risk assessment regarding their alcohol usage and addiction. Additionally, the couple’s relationship details and premarital goals are also significant to be stated on the form to allow the counselor in laying out guidelines and tips of how the couple can improve their affection and connection toward one another as well as succeed in their marriage. The form is also accompanied by an enclosed document which is a client service agreement form. This centers on presenting the payment information, cancellation policies, and limit of confidentiality conditions for the duration of the counseling session. To indicate an approval for the terms stated in the agreement, the couple must sign the form with their name and date of completion which will then be submitted to the counselor once every field is completed.
Marital Counseling Intake Form – Compared to the premarital counseling intake form, this document is intended to be used and completed by married couples who are in need of a counselor and adviser for sustaining their marriage. The first section of the form focuses on a graph that will be created by the couple to summarize and rate their personal satisfaction from the day they met each other to the day they got married. The suggestions of the couple regarding how they can improve individually are also stated on the first page of the form. Succeeding section of the form centers on a questionnaire and a rating scale identical to a survey form where the couple can indicate their level of happiness to the items identified on each question such as the intimacy of the spouse and the support that they get from one another.
Discernment Counseling Intake Form – Similar to a marital counseling intake, the user of this form is a married couple, however, couples who want to arrive at a decision whether they are better off with a divorce agreement or if their understanding is enough to maintain their family smoothly sailing. The period of a discernment counseling often rounds up to five sessions which highly depends on the length when the couple finalizes their marriage decisions. With this, a discernment counseling intake form mainly contains a questionnaire and a rating area for each spouse to indicate if their marriage is showing symptoms of a probable divorce or not. In addition, a notice form and a client contract are included to inform the couple about the rules and regulations pertaining to the counseling services that will be provided by the counselor.
Child Custody Recommending Counseling Intake Form – When a couple gets a divorce, not only will they need to plan out how to manage and separate their properties but also how they can provide for their children. With this, a child custody recommending counseling intake form must be completed by each party or the once married couple and submit the form to their legal representatives. The form contains ten sections that each party must fill in with data and answers. The first section is allotted for the user’s personal information which includes his name, phone numbers, current address, date of birth, and the identification of the other party. The second section is the employment information area where the user can indicate the name of his employer, his number of working hours in a day, and his work schedule for each week. Then, the name of the user’s attorney is disclosed on the third section of the form which will then be followed by the names of the members of the household and the children of the couple. A domestic violence questionnaire is enlisted on the fifth section to determine whether there are restraining orders and if there is a need for a safety plan to be created for the welfare of the children and the user. Lastly, the details about child and alcohol abuse, as well as the name of the user’s current partner, are also necessary for completing the form, which will end with the user’s signature implying truth and accuracy in the disclosed data on the form.
Co-Parenting Counseling Intake Form – Although the purpose of this form is highly identical to the aforementioned child custody recommending counseling intake form, this does not demand the identification of an attorney for it to be completed. Also, the form is presented by a parenting counselor and not a member of a legal court, which is why it has a simple outline that focuses on the general issues of the divorced couple. Insurance billing information, the names of the couple’s former therapists, the names of the children, as well as the goals and objectives of the couple toward their children will be indicated on the form.
Legal counseling intake forms are documents that can be used by businessmen and organizations for helping individuals settle their legal issues:
Financial Counseling Intake Form
Foreclosure Counseling Intake Form
Homebuyer Counseling Intake Form
Financial Counseling Intake Form – This form is used by individuals who aim to acquire a financial issue resolution. The form collects the personal details of the financial client along with his financial plans. Since financial counselors need sufficient details about the client’s financial status, it is significant that the client will disclose all matters relating to his financial problem, such as his monthly expenditures, and even the names of the financial aid providers where he applied for a financial assistance. A disclosure of interests and a third-party authorization form is enclosed with the document to inform the client about the scope of information to be disclosed to other parties, the disclosure duration, the purpose of the discussion, and the intention of processing a mandatory reporting for the financial counselor’s documentation.
Foreclosure Counseling Intake Form – Settling mortgage issues and helping homeowners manage their finances are the services that foreclosure counselors and advisers provide. With this, a foreclosure counseling intake form will gather the name of the homeowner whose house is on a mortgage, his residential address, his employment information such as his employment history and income verification, as well as the description of the property in foreclosure. Other details that are collected in this document includes the household monthly expenses of the homeowner and the types of loans that the homeowner currently has.
Homebuyer Counseling Intake Form – Before anyone can purchase a house, home ownership centers provide counselors and advisers for the homebuyers. These professionals use homebuyer counseling intake forms for their clients in order to acquire their basic details and to know what type of houses will be suitable for the preferences, interests, and the capability of the buyer. The form is enclosed with a disclosure statement which is essential for informing the homebuyer about his freedom in choosing a mortgage loan provider and a home that he wants to purchase at the end of the counseling sessions regardless of what the counselor had presented to him.
Personal counseling intake forms are used by any individual who seeks counseling services for his personal issues and concerns:
Grief Counseling Intake Form
Lifestyle Counseling Intake Form
Ministry Counseling Intake Form
Prenatal Genetic Counseling Intake Form
Grief Counseling Intake Form – Individuals who have experienced the loss of their loved ones are the target users of this form. A grief counseling intake form will collect the name of the client, the name of the deceased person, date of the deceased’s death, as well as the relationship of the client to the deceased person. The client must disclose his specific reactions and experiences evident during and after the death of his loved one. This information will allow the counselor or therapist to determine what steps and techniques must be recommended to the client in order for him to cope up with the changes in his life after the loss of the person he values the most. On the other hand, the form also has a section that is allotted for clients whose pets died. This section of the form will have the name of the pet, the pet’s age, species, date of death, the length of relationship that the client and pet had, and the circumstances of the loss.
Lifestyle Counseling Intake Form – Different people live in different lives with varying routines, food choices, and even sleeping habits. However, some people want to change the way they live life, the way they perceive things, and how they manage their everyday living. With this, they look for a lifestyle counselor’s service and fill out lifestyle counseling intake forms before they are welcomed to a scheduled counseling session. The form contains three pages that focus on the well-being, routine, and the choices of the client.
Ministry Counseling Intake Form – This form is used by members of a ministry or church group. The user of the form will be able to disclose his personal experiences which may have led to the issues and problems he is dealing with in life. Additionally, questions regarding the user’s belief and religion are also indicated on the form as well as a consent agreement that must be signed by the user to certify that he willingly desires to take counseling sessions from the ministry’s counselor.
Prenatal Genetic Counseling Intake Form – Women who aim to assure that their soon-to-be child is safe in their womb and in their family take prenatal counseling. These mothers are provided with prenatal genetic counseling intake forms that they must complete with their information. The form will indicate the identification of the client and his partner, the number of the client’s pregnancy and children, and the list of the client’s main concerns about her pregnancy.
Minor Counseling Intake Form
Benefits of Using Counseling Intake Forms
The reason why counseling intake forms are being used by counselors is due to the need of acquiring sufficient data about the client and to know the client’s intentions in scheduling a counseling session with the counselor. With this, the document serves as an effective tracking form that allows the center to categorize their clients and determine who is the applicable counselor to resolve the client’s issues. Another benefit is that the form protects the counselor from dealing with clients who are not responsible for paying their sessions. The counselor is protected since the form has laid out the terms, conditions, and an acknowledgment statement regarding the client’s billing obligations. Once the client signed the form, the document can be a strong evidence that a formal and legal agreement has been done between the client and the counseling center.
Nutritional Counseling Intake Form
The aforementioned benefits are just some of the commonly known advantages in the field of counseling and therapy businesses. With this, a counseling center can acquire more benefits depending on how they use the form and where they will be using the client’s disclosed data. Nonetheless, securing that the client’s information will not be used without the client’s appropriate consent should be included as one of the top priorities of any counselor in order to promote confidentiality and trustworthiness in this profession as well as his business.
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