Counseling Consent and Intake Form

Counseling Consent and Intake Form — Form Fields

This healthcare template includes 11 fields. Collect consent and background information from new counseling clients before their first session. Free to customize and use on ZenBuild.

• Full Name (text, required)
• Email Address (email, required)
• Phone Number (text, required)
• Date of Birth (text, required)
• Preferred Pronoun (dropdown selection, optional) — options: He/Him, She/Her, They/Them, Prefer Not to Say
• Primary Reason for Seeking Counseling (dropdown selection, required) — options: Anxiety, Depression, Relationship Issues, Grief, Trauma, Work Stress, Life Transitions, Other
• Briefly Describe What Brings You to Counseling (long text, required)
• Have You Attended Counseling Before? (multiple choice, required) — options: Yes, No
• Are You Currently Taking Any Medications? (multiple choice, required) — options: Yes, No
• How Did You Hear About Us? (checkboxes, optional) — options: Google Search, Social Media, Doctor Referral, Friend or Family, Insurance Directory
• Do You Agree to the Counseling Informed Consent? (multiple choice, required) — options: Yes, I Agree, No