Copy this intake questionnaire template for your next intake session
A clear intake questionnaire helps you gather the information you need before or during a first appointment: client demographics, presenting concerns, risk factors, treatment history, goals, and practical details that affect care. The template below is designed for behavioral health providers, including therapists, counselors, social workers, psychologists, psychiatrists, and other mental health professionals.
You can copy this template into your EHR, practice management system, secure form tool, or intake packet. Edit it for your license type, client population, state requirements, payer expectations, and practice policies. If you work with minors, couples, families, mandated clients, or higher-acuity clients, add the sections your setting requires.
Free intake questionnaire template
Client Name: ___________________________
Date of Birth: ___________________________
Date Completed: ___________________________
Preferred Name: ___________________________
Pronouns: ___________________________
Phone: ___________________________
Email: ___________________________
Address: ___________________________
Emergency Contact: ___________________________
Relationship to Client: ___________________________
Emergency Contact Phone: ___________________________
Reason for seeking services
What brings you to therapy or behavioral health services at this time?
__________________________________________________________________
How long has this been a concern?
__________________________________________________________________
What would you like to be different as a result of treatment?
__________________________________________________________________
Rate your current level of distress from 0 to 10: ______
Current symptoms and concerns
Please check any concerns you are currently experiencing:
- Anxiety, panic, or excessive worry
- Depressed mood, low motivation, or loss of interest
- Sleep problems or fatigue
- Relationship, family, school, or work stress
Additional concerns may include trauma-related symptoms, grief, anger, substance use, eating concerns, attention problems, mood changes, or difficulty completing daily responsibilities.
Other current concerns:
__________________________________________________________________
Mental health treatment history
Have you received therapy, counseling, psychiatric care, or other behavioral health services before?
☐ No ☐ Yes
If yes, when and where did you receive services?
__________________________________________________________________
What was helpful or unhelpful about past treatment?
__________________________________________________________________
Have you ever been hospitalized for mental health or substance use concerns?
☐ No ☐ Yes If yes, please describe: ___________________________
Medical history and medications
Do you have current medical conditions that may affect treatment?
☐ No ☐ Yes If yes, please describe: ___________________________
Current medications, including psychiatric medications:
__________________________________________________________________
Medication allergies or adverse reactions:
__________________________________________________________________
Primary care provider or prescribing provider, if applicable:
__________________________________________________________________
Risk and safety screening
Have you had thoughts of harming yourself recently?
☐ No ☐ Yes If yes, please describe: ___________________________
Have you had thoughts of harming someone else recently?
☐ No ☐ Yes If yes, please describe: ___________________________
Have you experienced recent abuse, violence, exploitation, or feeling unsafe?
☐ No ☐ Yes If yes, please describe: ___________________________
Do you have access to firearms or other lethal means?
☐ No ☐ Yes Prefer not to answer
Substance use
Do you currently use alcohol, cannabis, prescription medication not as prescribed, or other substances?
☐ No ☐ Yes
If yes, please describe type, frequency, amount, and any concerns:
__________________________________________________________________
Have you ever received substance use treatment or attended recovery support services?
☐ No ☐ Yes If yes, please describe: ___________________________
Social, family, school, and work context
Who lives in your household?
__________________________________________________________________
Key relationships or support people:
__________________________________________________________________
Current work, school, caregiving, or military responsibilities:
__________________________________________________________________
Cultural, spiritual, identity, or community factors you would like your provider to understand:
__________________________________________________________________
Goals and preferences for care
What are your top 1 to 3 goals for treatment?
- ______________________________________________________________
- ______________________________________________________________
- ______________________________________________________________
What helps you feel comfortable in treatment?
__________________________________________________________________
Are there topics, approaches, or past experiences you want your provider to be aware of?
__________________________________________________________________
Administrative information
Insurance or payment method: ___________________________
Referral source: ___________________________
Preferred appointment format: ☐ In person ☐ Telehealth ☐ Either
Availability for appointments: ___________________________
Client signature: ___________________________
Date: ___________________________
Completed intake questionnaire example
This sample shows the level of detail that can help a clinician prepare for an intake assessment. It is fictional and should not be copied into a real client record.
Client information
Client Name: Jordan M.
Date of Birth: 04/18/1992
Date Completed: 09/10/2026
Preferred Name: Jordan
Pronouns: They/them
Emergency Contact: Riley M., sibling, 555-0148
Reason for seeking services
Jordan reports increased anxiety over the past six months, especially before work meetings and at night. They describe racing thoughts, muscle tension, difficulty sleeping, and avoidance of social plans. Jordan states, “I keep thinking I’m going to mess something up, even when nothing bad has happened.” Current distress is rated 7 out of 10.
Current symptoms and history
Jordan checked anxiety, sleep problems, low motivation, work stress, and relationship stress. They attended therapy briefly in college and found grounding exercises helpful. No prior psychiatric hospitalization was reported. Jordan takes medication for migraines and denies current psychiatric medication. They report no medication allergies.
Risk and safety
Jordan denies current thoughts of self-harm or harm toward others. They deny recent abuse or feeling unsafe. They report no firearm access. They state that if distress increases, they would contact their sibling, use a crisis line, or go to the nearest emergency department if needed.
Substance use and social context
Jordan reports drinking alcohol socially, usually one to two drinks on weekends, and denies other substance use. They live with a partner and work full-time as a project coordinator. They identify their sibling and two close friends as primary supports. Jordan would like therapy to include practical coping skills, support with boundaries, and help reducing avoidance.
Initial goals
- Reduce anxiety symptoms and improve sleep.
- Build coping skills for work-related stress.
- Improve communication and boundaries in relationships.
When to use an intake questionnaire
An intake questionnaire is most useful before the first clinical appointment or at the start of an intake session. It gives the clinician a structured way to collect background information without relying only on memory or unstructured conversation.
Many practices send the questionnaire through a secure client portal before the appointment. Others complete it with the client during the session, especially when the client has limited technology access, needs support with reading or writing, or presents with acute distress. For some clients, a shorter version works better. A 10-page packet may be too much for someone in crisis, while a longer form may be appropriate for psychological testing, intensive outpatient care, or psychiatric evaluation.
Use an intake questionnaire for:
- New individual therapy, counseling, psychiatry, or assessment clients
- Clients returning after a long break in services
- Transfers from another clinician or program
- Periodic updates when symptoms, medications, risk, or life circumstances change
The questionnaire should support the intake interview, not replace it. Client answers often need follow-up questions, clarification, and clinical judgment. For example, a checked box for “sleep problems” may reflect anxiety, depression, trauma symptoms, substance use, a medical condition, shift work, or parenting demands.
How this template supports intake documentation
A good intake form does more than collect facts. It helps you prepare for the clinical assessment and write a more organized intake note. The sections in this template map to common documentation needs: presenting problem, relevant history, risk screening, strengths, supports, barriers, treatment goals, and care preferences.
For example, the client’s statement about wanting “less anxiety at work” can inform the presenting concern and early treatment goals. A past positive response to grounding skills may guide initial interventions. Medication and medical history may help determine whether coordination with a prescriber or primary care provider is appropriate, with proper consent.
The questionnaire can also reduce missed items. During a first session, it is easy to focus on the most urgent concern and forget practical details such as emergency contact information, appointment preferences, or prior treatment history. A consistent form gives each client the same starting structure while still allowing room for narrative answers.
What to customize before using this form
This template is a starting point. Most clinicians should adjust it before adding it to their documentation workflow. Your intake questionnaire should match the services you provide, the clients you serve, and the requirements that apply to your setting.
Consider changing the form based on:
- Client population: Children, adolescents, couples, families, and older adults often need different questions.
- Service type: Therapy, psychiatry, psychological assessment, group therapy, and substance use treatment may require different details.
- Practice policies: Add your consent, privacy, telehealth, payment, cancellation, and communication policies separately as needed.
- Clinical risk level: Higher-acuity settings may need more detailed safety, crisis, and care coordination questions.
If you work with minors, include parent or guardian information, custody considerations, school details, developmental history, and consent requirements. If you provide couples or family therapy, clarify who the client is, how records are handled, and how confidentiality works within the service. If you provide psychiatric care, medication history and prior medication trials may need more space.
Common intake questionnaire mistakes to avoid
Small form design problems can create extra work later. The goal is to collect enough information to guide care without overwhelming the client or creating a packet no one wants to complete.
Asking too many questions before rapport exists
Some clients are willing to complete detailed forms. Others may feel exposed, confused, or discouraged by a long intake packet. Keep the core form focused. Save deeper assessment questions for the intake interview or later sessions when clinically appropriate.
Using vague prompts
A question like “Describe your history” often produces either a blank response or several pages of unfocused information. More specific prompts work better. Ask about current concerns, duration, prior treatment, what helped, what did not help, and what the client wants from care.
Treating checkboxes as the full clinical picture
Checkboxes are useful for screening, but they need context. A client who checks “panic” may mean occasional stress surges, frequent panic attacks, medical symptoms, or trauma responses. Use the form to identify follow-up areas, then document your clinical assessment based on the interview.
Forgetting to update the questionnaire
An intake form can become outdated as your practice changes. Review it when you add telehealth services, change payment policies, adjust populations served, or update your documentation procedures. Many practices also review intake materials at least annually.
How AutoNotes helps after the questionnaire is complete
The intake questionnaire is only the first step. The time-consuming part often comes after the session, when you need to turn the client’s answers, your clinical interview, risk assessment, diagnostic impressions, and plan into a structured intake note.
AutoNotes helps behavioral health professionals create editable intake documentation drafts faster. Instead of starting with a blank page, you can use session details to generate a structured draft that includes relevant areas such as presenting problem, history, symptoms, risk factors, client strengths, initial goals, clinical impressions, and next steps.
Clinicians remain responsible for reviewing, editing, and finalizing every note. That matters. AI-assisted documentation should support your writing process, not make clinical decisions for you. AutoNotes is designed around behavioral health workflows, with templates for services such as intake sessions, assessments, individual therapy, group therapy, treatment planning, and progress notes.
This can be especially helpful if you tend to finish intakes with several pages of raw information but limited time to organize it. AutoNotes gives you a cleaner starting point, while you decide what belongs in the final clinical record.
A faster path from intake form to finished note
A strong intake questionnaire helps you collect the right information. A structured documentation process helps you use that information without spending your evening rewriting it from scratch.
If intake notes are slowing down your practice, AutoNotes can help you create organized, editable drafts for intake sessions and other behavioral health services. You stay in control of the final note, including clinical language, diagnosis, treatment plan details, and any required edits.
Start your free trial and see how AutoNotes can support a faster, more consistent documentation workflow for your practice.
