Initial intake and mental health screening, treatment plan and therapy agreement, session notes (SOAP), progress reviews, and termination summaries for psychology counseling practices and licensed therapists
Get started with PocperWelcome. This intake helps us understand what you are bringing to therapy and how we can best support you. Take your time, share what feels comfortable, and skip anything you would rather discuss in person — we can revisit any section together.
Full legal name:
Date of birth:
Preferred name:
Pronouns:
Email:
Phone:
Mailing address:
Occupation:
Employer / school:
Marital status:
Single
Partnered
Married
Separated / divorced
Widowed
Prefer not to say
Contact name:
Relationship to you:
Phone:
How did you hear about us? Select all that apply.
Self-referred
Physician / medical provider
Family member or friend
School or university counselor
Employer / EAP
Online directory or search
Other
Referring contact name:
Referring contact phone or email:
In your own words, what brings you in today?
Concern | Frequency | Severity (1-10) | Notes |
Anxiety | |||
Depression / low mood | |||
Trauma or PTSD | |||
Grief or loss | |||
Relationship issues | |||
Family conflict | |||
Work or school stress | |||
Life transition | |||
Identity or self-discovery | |||
Sleep difficulties | |||
Addiction or compulsive behaviors | |||
Eating concerns | |||
Chronic stress or burnout | |||
Self-esteem | |||
Other (please describe in the notes above) |
When did this begin or get more difficult?
Severity right now (1 = mild, 10 = severe):
How often do these difficulties show up?
Daily
Most days
A few times per week
Occasional / situational
How is this affecting your daily life — work, relationships, sleep, eating?
Anything from earlier in life you would like us to know?
Have you been in therapy before?
Yes
No
When (year):
Where / with whom:
Approximate duration:
Previous diagnoses, if any:
I have had a psychiatric hospitalization
If yes, please share what feels okay to share:
Sometimes thoughts of suicide or self-harm come up. Knowing this helps us care for you well — there are no wrong answers.
I have never had thoughts of suicide or self-harm
I have had such thoughts in the past, not currently
I have such thoughts occasionally
I have such thoughts frequently
If you would like to share more, you can write it here. You can also leave this blank and we can talk about it together.
Current psychiatric medications — name, dose, prescriber:
Other medications, supplements, or vitamins:
Medical conditions or chronic health concerns:
Allergies:
Alcohol use:
Never
Rarely
Weekly
Daily
Cannabis or other recreational substances:
Never
Rarely
Weekly
Daily
I have received treatment for substance use
If yes, please share what is helpful for us to know:
If comfortable, please share any history of trauma. You may skip this entirely; we can revisit it together later when it feels right.
Who do you usually turn to when things are hard?
How would you rate your closest relationships overall (1 = strained, 5 = strong)?
Day-to-day, how connected do you feel?
Well connected
Somewhat connected
Often lonely
Mostly isolated
Average hours of sleep:
Sleep quality:
Restful
Mixed
Often disrupted
Insomnia / hypersomnia
Appetite:
Normal
Reduced
Increased / emotional eating
Exercise frequency:
Daily
A few times per week
Occasionally
Rarely
Spiritual, religious, or cultural background that is meaningful to you:
If therapy goes well, what would success look like for you?
Your readiness to begin therapy (1 = unsure, 10 = fully ready):
Any concerns or hesitations about starting therapy?
Therapy is confidential, with a few exceptions explained below. Please review and confirm your understanding.
I understand that the therapist may need to act on disclosures involving abuse of a child or vulnerable adult
I understand that imminent risk of serious harm to myself or others may require additional steps to keep me and others safe
I understand that records may be requested by a court order
I agree to discuss any of the above with my therapist as needed
I have received written notice of these confidentiality limits
Client signature:
Therapist signature:
Intake date:
I have completed this intake to the best of my ability
Thank you for taking the time to share. Whatever you have written is a solid starting point — we will go through it together and decide next steps at a pace that suits you.
The Initial Intake & Mental Health Screening template is a ready-to-use form from Pocper's Psychology Counseling Practice pack. Customize the fields to match your workflow, then share a link so clients can complete it and upload documents in real time.