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New Therapy Client Psychology Intake Assessment

A pre-first-session intake for therapy and counseling practices, covering presenting concerns, symptom frequency, daily-life impact, treatment history, and goals for care. An AI follow-up interview explores the story behind the client's main concern — what changed recently, what they've tried, and what a good outcome looks like — so clinicians arrive at session one already oriented.

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Sample questions

A preview of what’s in the template. Every question is editable before you launch.

14 questions · ~7 min
Q01
Message

Welcome, and thank you for taking this step. Before your first session, we'd like to understand a bit about what's bringing you here so your therapist can prepare. This takes about 6-8 minutes, and there are no wrong answers — please answer as honestly as you can.

Q02
ConsentRequired

Before we begin, please confirm you understand how this information will be used.

Q03
Multiple ChoiceRequired

What brings you to seek support right now? (Select all that apply)

  • Anxiety or worry
  • Low mood or depression
  • Relationship difficulties
  • Work, school, or career stress
  • Grief or loss
  • A past or ongoing traumatic experience
  • Sleep difficulties
  • Substance use
  • Self-esteem or identity concerns
Q04
Long Text

In your own words, what's been going on that led you to seek support right now?

Q05
MatrixRequired

Over the last 2 weeks, how often have you experienced each of the following?

6 rows × 4 columns
  • Trouble falling or staying asleep
  • Feeling anxious or on edge
  • Feeling down or hopeless
  • Difficulty concentrating
  • Irritability or anger
  • +1 more
Columns: Not at all · Several days · More than half the days · Nearly every day
Q06
Opinion ScaleRequired

Overall, how would you rate your emotional wellbeing over the past month?

Scale: 0 – 10
Min:As bad as it getsMax:As good as it gets
Q07
Slider Matrix

How much has what you described affected the following areas of your life recently?

5 rows, one slider each
  • Work or school performance
  • Relationships with family or friends
  • Sleep
  • Physical health
  • Ability to enjoy daily activities
Slider 0–10Min:Not affected at allMax:Severely affected
Q08
Multiple ChoiceRequired

Which of these currently apply to you?

  • Currently seeing a therapist or counselor
  • Have seen one in the past but not currently
  • Currently taking medication prescribed for a mental health condition
  • Have taken such medication in the past
Q09
AI Interview

Explore the client's primary presenting concern in depth: what changed recently that brought them to seek help now, how long they've noticed the issue, what they've already tried on their own to cope, and what a good outcome from therapy would look like to them. If they disclose thoughts of self-harm, suicide, or being in immediate danger, do not probe further clinically — acknowledge with care, clearly direct them to contact emergency services or a crisis line right away, and end that line of questioning.

Q10
Ranking

Rank the following goals in order of what you'd most like to focus on in therapy, from most to least important.

  1. Reduce anxiety or worry
  2. Improve mood
  3. Better manage stress
  4. Improve relationships
  5. Process a difficult past experience
  6. Build coping skills
  7. Improve sleep
  8. Better understand myself
Drag to rank
Q11
Short Text

Is there anything else you'd like your therapist to know before your first session?

Q12
Multiple Choice

What is your age range? (Optional — helps your therapist tailor their approach)

  • Under 18
  • 18-24
  • 25-34
  • 35-44
  • 45-54
  • 55-64
  • 65 or older
  • Prefer not to say
Q13
Multiple Choice

What is your gender identity? (Optional)

  • Woman
  • Man
  • Non-binary
  • Prefer not to say
Q14
Message

Thank you for sharing this with us — we know it isn't always easy. Your therapist will review these answers before your first session so you can spend that time on what matters most to you.

What’s included

  • AI follow-ups

    Adaptive probes on open-ended answers that pull out detail a static form would miss.

  • Attention checks

    Built-in safeguards against rushed answers and low-quality respondents.

  • AI-drafted copy

    Wording, ordering, and branching written by the AI — tuned to your research goal.

  • Auto report

    Themes, quotes, and a plain-English summary write themselves once responses come in.

How it compares

We reviewed the closest templates from other survey tools. Here’s what they do well — and where this template goes further.

Why this template

  • Uses a consent step and welcome message to set an ethical, transparent tone before any clinical questions are asked
  • Combines structured screening (symptom-frequency matrix, wellbeing rating, impact sliders) with an open-ended narrative question so clinicians get both quantifiable and qualitative context
  • Includes an AI follow-up interview that specifically probes the story behind the presenting concern — what changed recently, what's been tried, and what a good outcome looks like — so the therapist isn't starting from zero at session one
  • Ends with a ranking of therapy goals, optional demographic questions, and a closing message from the practice, giving therapists a prioritized, respectful, session-ready summary

SurveyMonkey

Client Intake Form Template

A generic, industry-agnostic client intake template rather than one built for mental health or counseling settings. It's fielding-ready as a basic form but has no clinical language around presenting concerns, symptom frequency, or treatment history. Useful as a starting point that a practice would need to substantially customize.

What it does well

  • Quick to deploy generic intake form
  • Backed by SurveyMonkey's established survey infrastructure and reporting
  • Broad applicability across business types

Where it falls short

  • Not designed for mental health/therapy intake — lacks symptom, impact, and treatment-history structure
  • Static question set with no adaptive follow-up to explore a client's story
  • No transparent prompt methodology or automated quality scoring of open responses

SurveySparrow

Sample client intake form template

Another general-purpose client intake template, positioned for business use broadly rather than therapy or counseling practices specifically. It offers a printable/conversational form format but no clinical framing for pre-session mental health intake. Would require significant rework to cover symptom screening or treatment goals.

What it does well

  • Conversational form style that can feel less clinical/intimidating
  • Printable option for in-office use
  • Flexible across business use cases

Where it falls short

  • No mental-health-specific content (symptom frequency, daily-life impact, treatment history)
  • No adaptive AI interview to explore the presenting concern further
  • No built-in quality scoring or auto-generated clinical summary report

Ready to launch?

Open this template in the editor. Every part is yours to change before the first respondent sees it.

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