New Client Counseling Intake Assessment

Welcome, and thank you for taking this step. This intake helps your counselor understand what's brought you here before your first session. It takes about 6-8 minutes, your answers are confidential within the limits explained next, and you can skip anything you're not ready to answer.

Before we begin, please review the following.

What's bringing you to counseling right now? Select all that apply.

• Anxiety or worry
• Low mood or depression
• Relationship or family conflict
• Grief or loss
• Work or academic stress
• A specific past experience or trauma
• Life transition (move, job, breakup, etc.)
• Self-esteem or identity
• Substance use
• Not sure yet

In your own words, what's been going on lately, and what made now the right time to reach out?

Overall, how would you rate your emotional well-being over the past two weeks?

Over the past two weeks, how often have you experienced each of the following?

In the past two weeks, have you had any thoughts of harming yourself or that life isn't worth living?

• No
• Yes
• Prefer not to answer

If you're in crisis or thinking about harming yourself right now, please contact 988 (Suicide & Crisis Lifeline) or your local emergency number immediately — you don't need to wait for your first session. (Template note: replace with the correct crisis line for your country/region before launching.)

Have you received counseling or therapy before?

• No, this is my first time
• Yes, in the past
• Yes, I'm currently also seeing another provider
• Prefer not to say

Rank the following in order of what you most want to get out of counseling, starting with your top priority.

1. Reduce anxiety or worry
2. Improve a relationship or communication
3. Process grief or loss
4. Manage stress or burnout
5. Work through a specific past experience
6. Build self-esteem or confidence

Explore the client's top-ranked goal and their earlier description of what's going on: ask when this started, what tends to trigger or worsen it, what they've already tried to cope with it, and what a realistic 'better' would look like to them in a few months. If they picked 'not sure yet' for their concerns or left the description blank, gently help them articulate what prompted them to reach out now rather than pressing for a diagnosis.

Which session format works best for you going forward?

• In-person
• Video call
• Phone call
• No preference

What is your age range?

• Under 18
• 18-24
• 25-34
• 35-44
• 45-54
• 55-64
• 65+
• Prefer not to say

What is your gender identity?

• Woman
• Man
• Non-binary
• Prefer not to say

Thank you for sharing this with us. Your counselor will review these answers before your first session so you can spend more of that time on what matters most to you. If you selected that you're having thoughts of self-harm, someone from our team may reach out before your appointment to check in.