Therapy Intake Forms Behavioral Health
Intake forms: Counseling
Intake forms for counseling are a critical—yet often overlooked—part of psychotherapy and are given to the client at the beginning of counseling. The proper therapy intake forms are crucial to effective therapy. Indeed, they set the tone and boundaries for successful treatment.
However, filling out counseling intake forms is not something people want to do. As a therapist, you want to achieve a balance that makes completing therapy intake forms as painless as possible. You need to ensure that the intake process is not aversive to the client while, at the same time, making sure you-and them-are receiving the necessary information. Here is what you need to know about therapy intake forms.
Intake forms in counseling
Although various therapy intake forms are completed during the intake process, there is usually one main document that is labeled the “intake form”. The counseling intake form provides you with the initial background on the client. Besides asking for basic demographic information, the therapy intake form may include past psychiatric treatment, medications, reasons for seeking therapy, and family history.
Keep in mind that the therapy intake form will be tailored for the type of counseling you perform. For example, a counselor that sees mainly couples will likely include questions about relationships, whereas a child therapist would focus on issues pertinent to children. The therapy intake form acts as a first step for the areas that need to be addressed in treatment. Additionally, a therapist often has a large caseload and it can be difficult to remember everyone’s background. An intake form is a valuable resource that a clinician can refer to as a base of information about a particular client.
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List of counseling intake forms needed in the private practice
|Type of intake form||Purpose|
|Consent for services||Outlines what a client should expect from therapy and the specific rules for your practice.|
|Notice of privacy practices||Clients should know the rights to their information and how you plan to keep it safe and could include state-specific rules about privacy and confidentiality.|
|Release of information||Permits therapists to share a client’s information with other people when relevant.|
|Social media/Internet policy||Because of the need for strong boundaries in counseling, this policy lays out the rules of engagement and boundaries for virtual interactions with clients.|
Consent for Services
It is recommended that you discuss the following areas when using the “consent for services” intake form:
- The description of how therapy works, including assessment procedures and expected course of treatment.
- How to make and cancel appointments and how long those appointments will last.
- How much sessions cost and the fees assessed if clients cancel late or don’t show up.
- Is insurance accepted and how will insurance claims be processed? It is also necessary to let a client know that insurance companies will require a diagnosis and want access to other personal information, such as a treatment plan. Additionally, it is critical to recognize that insurance reimbursement may be limited to a certain number of sessions.
- Appropriate ways to make contact with the therapist and emergency procedures.
- How records of treatment are kept and what is included in those records.
- Clients need to be informed that they have a right to their file but it is recommended that if they choose to see their record, they discuss the contents with their therapist.
- If a therapist sees children, it is helpful to let parents know their role in the treatment and what you will or will not be able to share with them regarding their child’s therapy.
Over the course of therapy, service-related questions will inevitably arise. This counseling intake form goes a long way toward setting proper expectations and avoiding future confusion and conflict.
Notice of Privacy Practices
While some people may include privacy practices in the same form in which they describe their services, it is important enough to deserve its own document. Every state has its own rules about privacy and confidentiality, so you will need to check with your state licensing board for the specific laws. However, you can expect to talk about the rules of confidentiality and a client’s rights in therapy.
It is especially important to discuss the limits of confidentiality, including instances where confidentiality must be broken, such as child abuse and self-harm. There is always a chance that confidentiality will need to be breached and it is best to be clear with the client from the beginning. Otherwise, they may claim they did not know and it will turn into a very difficult situation. It is not an overstatement to say that the whole therapeutic process can be threatened due to a lack of client education about confidentiality.
For example, imagine telling a minor client that you have to contact Child Protective Services about an alleged abusive situation when they thought everything they said was confidential. That is going to deal a lot of damage to the therapeutic relationship. It is much easier if adult clients, parents, and children are told at the intake session about all the possible ways that confidentiality could be broken.
Further, after reviewing this intake form, clients should know the rights to their information and how you plan to keep it safe. For example, did you know that a client has a right to try to restrict who sees the documentation about their case? Or, that they may request you to change their record if they believe it contains incorrect information? What’s more, a client needs to know the steps you have taken to ensure that no one else can obtain their information without consent. This may include using HIPAA-compliant teletherapy software and encrypted electronic record-keeping.
Release of Information Form
The “release of information” form permits therapists to share a client’s information with other people. Some therapists have clients sign a blanket release of information form at the beginning of treatment. Others do it as the need arises. Doing it at the intake stage gives you the flexibility to talk about the case as needed with other professionals. However, it is always a good idea to inform the client you are discussing their case with others as it occurs. For instance, if you feel it would be helpful to discuss your client’s case with another person, it is good practice to discuss it directly with the client at the appropriate time and have them fill out a release of information in front of you during the session. After all, transparency is one of the keys to a therapeutic collaboration.
Social Media Policy and Internet Policy
Private Practice Considerations
Therapists that work as part of an institution don’t have to worry about the content or type of therapy intake forms they provide a client. They just give them the counseling intake forms that their organization requires and let them worry about the particulars. However, private practice therapists—unless they are part of a group practice—usually have to make all the decisions regarding the type and content of counseling intake forms.
Here are some areas to think about involving therapy and counseling intake forms in private practice:
- If you are in therapy private practice, you must have a website. This is a place that the client can visit for information about your practice and a home base for their therapy. Often, the website is linked to practice management software that includes all the necessary counseling intake forms. It is always a good idea to be able to access counseling intake forms online. And it is much more efficient to ask clients to fill them out before they ever show up for their first session. Not only does it save valuable time that might otherwise eat into the intake session, but it also sets the stage to discuss the presenting problem and therapy expectations for the client.
- It may be tempting to merge many of these counseling intake forms into one or two long documents but it isn’t recommended. It is better to keep counseling intake forms separate to give them individual emphasis and make them stand out. Besides, an overly long document screams “don’t read me”.
- One of the disadvantages of private practice is that you don’t have help when conflict arises. Agencies and institutions have built-in support systems that handle problems as they come up. In private practice, counseling intake forms may act as your backup in certain cases. If an issue arises during treatment that was previously presented in a counseling intake form, it acts as evidence that the client knew about it. For example, a client may claim that they never knew they weren’t supposed to message you on Facebook. But if you have the social media policy form that they signed, you are covered. As any lawyer will tell you, nothing exists if it is not in writing. The counseling intake forms are a way to prove you already discussed the issue.
- Some people in private practice still use paper records. For whatever reason, they don’t trust the internet and electronic record keeping. First of all, if you still use paper records you should stop and invest in practice management software. It makes everything easier for you and the client and the security of electronic records has come a long way in the past decade. If, for some reason, you still want to kick it old school, keep all documentation under double lock and key. And never leave the office before you make sure that no client papers are lying around.
- Private therapy practitioners are often starting from scratch when it comes to creating counseling or therapy intake forms. A great resource for clinicians starting a practice is the Center for Ethical Practice website, run by an expert in therapist ethics, Mary Alice Fisher, Ph.D. The site has free therapy intake forms that you can use as a guide for your own counseling intake forms. Just a little warning: the example therapy intake forms on the site are very thorough; these therapy intake forms include phrases meant to cover every possible ethical dilemma. You will probably want to pare them down for your own use but these therapy intake forms act as a comprehensive guide for what you will want to cover.
General Tips For The Intake Process
- It is a mistake to talk to clients for the first time at an intake session. When possible, get a flavor for their case before they meet with you by talking to them on the phone. It is also helpful to have them fill out therapy intake forms before your first official meeting. This helps you prepare for the intake session and makes them feel more comfortable with therapy. It allows you (and them) to prepare follow-up questions related to what they put down on their counseling intake forms.
- Clients need to do more than just sign counseling intake forms. You need to make sure the client understands what they are signing. All therapy intake forms need to be gone over verbally as well as have the client read them for themselves. This gives you a chance to clarify any areas of confusion or concern.
- Along those same lines, you will want to find a balance on your counseling intake forms between providing too much detail or not enough. Therapy intake forms need to be detailed enough to contain the crucial points but not so much that the client gets overwhelmed with information.
- Some clients may terminate treatment without warning due to concerns they have with the therapist, the practice, or basic privacy issues. To prevent this, it is important to reiterate to clients that they should first come to the therapist with any problems they may have about privacy or practice operations outlined in the therapy intake forms. Putting a line or two about that on the service consent form makes it more likely that the client will come to the therapist with their future worries.
How Do I Make Intake Easier?
Counseling intake forms are a tedious—yet necessary—part of the counseling process. Despite their dullness, therapy intake forms serve many important functions. First, therapy intake forms provide background information to the therapist that they can use throughout treatment. Next, therapy intake forms provide the client with clear expectations and boundaries for therapy. Finally, therapy intake forms act as an insurance policy for therapists in case conflict arises with the client.
You might be wondering, what is the simplest way to manage the intake process in an online world? In three words: practice management software.
Theraplatform is making it easier than ever for therapists to administer important counseling intake forms to clients.
- It allows clinicians to send clients relevant documents for their online review and enables them to fill them out, sign, and return them electronically. This can occur whenever the therapist desires; either right when they arrive at the intake appointment or days before the first appointment ever occurs (as mentioned above, we recommend the latter).
- With several clicks of the keyboard, the counseling intake forms are completed. It is all HIPAA compliant and electronically encrypted for the ultimate in client confidentiality. And you no longer have to worry about illegible handwriting.
- The system also tracks which clients completed the therapy intake forms and which are still missing.
- An additional benefit of using Theraplatform is that they have pre-prepared templates for all the counseling intake forms you need. What’s more, you can modify those templates to make them more to your liking or build one entirely from scratch.
- Therapists need clients to complete specific counseling intake forms to uphold the integrity of the counseling process. With the advancements in virtual therapy, it no longer has to be such a daunting task. You can test drive TheraPlatform for free for 30 days and no credit card is required. Sign up for a free trial today.
- Counseling treatment plan
- Counseling goals
- SOAP notes in counseling
- Couples and family therapy CPT codes
- Mental health billing
- The Ultimate Insurance Billing Guide for Therapists
- The Ultimate Teletherapy Ebook
- Therapy Resources