New Client Intake Form - Health Planet Psychotherapy

Personal Information

First Name

Last Name

Date of Birth

Gender

Phone Number

Email Address

Street Address

City

State

Emergency Contact

Contact Name

Contact Phone

Relationship

Insurance & Payment Information

Insurance Provider

Insurance ID/Policy Number

Preferred Payment Method

Reason for Seeking Services

What is your primary concern or reason for seeking therapy?

Please describe any symptoms you are experiencing

How long have you been experiencing these concerns?

I have received therapy or counseling before

Please provide details about your previous therapy experience

Medical & Mental Health History

Current Medications

Medical Conditions

Mental Health History

Substance Use History

Family Mental Health History

Therapy Goals & Preferences

What are your goals for therapy?

What are your expectations from therapy?

Preferred Therapist Gender

Preferred Session Time

Additional Information

How did you hear about us?

Is there anything else you would like us to know?

Consent & Authorization

I consent to treatment and understand the nature of psychotherapy services

I consent to receive communications via email and phone regarding my treatment

Welcome to Health Planet

Personal Information

Emergency Contact

Insurance & Payment Information

Reason for Seeking Services

Medical & Mental Health History

Therapy Goals & Preferences

Additional Information

Consent & Authorization

Book a Session

Welcome to Health Planet

Personal Information

Emergency Contact

Insurance & Payment Information

Reason for Seeking Services

Medical & Mental Health History

Therapy Goals & Preferences

Additional Information

Consent & Authorization

Book a Session

Complete Payment