Mental Health Session Intake and Consent Form

Mental Health Session Intake and Consent Form — Form Fields

This healthcare template includes 10 fields. Intake and consent form for new patients beginning outpatient mental health therapy. Free to customize and use on ZenBuild.

• Patient Full Name (text, required)
• Email Address (email, required)
• Date of Birth (text, required)
• Emergency Contact Name and Phone (text, required)
• Reason for Seeking Therapy (dropdown selection, required) — options: Anxiety, Depression, Trauma/PTSD, Relationship Issues, Grief, Stress Management, Life Transitions, Other
• Have you previously received mental health treatment? (dropdown selection, required) — options: Yes - Therapy, Yes - Medication, Yes - Both, No
• Briefly describe what brings you to therapy at this time (long text, required)
• Insurance Type (dropdown selection, required) — options: Private Insurance, Medicaid, Medicare, Self-Pay, Employee Assistance Program (EAP)
• I consent to telehealth sessions if applicable (checkboxes, optional)
• I have read and agree to the practice's privacy and cancellation policies (checkboxes, required)