Therapy Intake Form Template UK

The Therapy Intake Form Template UK is offered in multiple formats, including PDF, Word, and Google Docs, and comes with customizable and printable examples.

Open – Template

Online – Template

Sample

Therapy Intake Form Template UK

Editable – Printable

PDF – 1 PDF – 2

Therapy Intake Form Template UK

1. Client Information





2. Emergency Contact Information


3. Presenting Issues

4. Medical History

5. Previous Therapy Experience

6. Goals for Therapy

7. Consent for Treatment

8. Confidentiality Agreement

9. Signature and Agreement

10. Declaration and Signatures


PDF

WORD

Examples

Therapy Intake Form Template UK (1)
Client Information:
Full Name: [Client’s Full Name]
Date of Birth: [Client’s Date of Birth]
Address: [Client’s Address]
Phone Number: [Client’s Phone Number]
Email Address: [Client’s Email Address]
Emergency Contact:
Name: [Emergency Contact’s Name]
Relationship: [Relationship to Client]
Phone Number: [Emergency Contact’s Phone Number]
Referral Information:
How did you hear about us?: [Source of Referral]
Referring Professional (if applicable): [Referring Professional’s Name]
Presenting Issues:
Please describe the main issues you are experiencing: [Detailed description of issues and concerns]
Medical History:
Do you have any medical conditions?: [Yes/No]
If yes, please specify: [Details of medical conditions]
Are you currently taking any medication?: [Yes/No]
If yes, please list: [Names of medications]
Psychological History:
Have you previously received therapy?: [Yes/No]
If yes, please provide details: [Details of previous therapy, including duration and types of therapy]
Goals for Therapy:
What do you hope to achieve through therapy?: [Client’s therapy goals]
Consent:
Do you consent to participate in therapy and share your information as described?: [Yes/No]
Signed in [City], [Date].
Sincerely,
[Signature of the Client]
[Client’s Name]
Therapy Intake Form Template UK (2)
Client Details:
Full Name: [Client’s Full Name]
Date of Birth: [Client’s Date of Birth]
Address: [Client’s Address]
Phone Number: [Client’s Phone Number]
Email Address: [Client’s Email Address]
Emergency Contact Information:
Name: [Emergency Contact’s Name]
Relationship: [Relationship to Client]
Phone Number: [Emergency Contact’s Phone Number]
Referral Source:
How did you find us?: [Referral Source]
Referring Professional Information (if applicable): [Referring Professional’s Name]
Current Concerns:
Briefly outline the issues you wish to address: [Description of current concerns]
Health Background:
Do you have any known medical conditions?: [Yes/No]
If yes, please elaborate: [Details of medical conditions]
Are you on any medications currently?: [Yes/No]
If yes, please provide details: [Names of medications]
Previous Therapy Experience:
Have you ever engaged in therapy before?: [Yes/No]
If yes, please describe your experience: [Details of previous therapy experience]
Therapy Objectives:
What specific outcomes do you wish to achieve through therapy?: [Client’s objectives]
Agreement:
Do you agree to participate in therapy as outlined?: [Yes/No]
Signed in [City], [Date].
Sincerely,
[Signature of the Client]
[Client’s Name]

Printable

PDF – 1 PDF – 2

Therapy Intake Form Template UK