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New Client Counseling Intake Assessment

A pre-session intake for therapy and counseling practices that captures presenting concerns, symptom frequency, safety screening, and personal goals before the first appointment. An AI follow-up interview explores the client's own account of what's going on and what they hope will change, giving clinicians richer context than checkboxes alone before the first session.

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Sample questions

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

15 questions · ~8 min
Q01
Message

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.

Q02
ConsentRequired

Before we begin, please review the following.

Q03
Multiple ChoiceRequired

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
Q04
Long Text

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

Q05
Opinion ScaleRequired

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

Scale: 1 – 10
Min:Struggling a great dealMax:Doing very well
Q06
MatrixRequired

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

8 rows × 5 columns
  • Trouble sleeping or sleeping too much
  • Changes in appetite
  • Low energy or fatigue
  • Difficulty concentrating
  • Feeling anxious or on edge
  • +3 more
Columns: Never · Rarely · Sometimes · Often · Nearly every day
Q07
Multiple ChoiceRequired

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
Q08
Message

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.)

Q09
Multiple Choice

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
Q10
Ranking

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
Drag to rank
Q11
AI Interview

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.

Q12
Multiple Choice

Which session format works best for you going forward?

  • In-person
  • Video call
  • Phone call
  • No preference
Q13
Multiple Choice

What is your age range?

  • Under 18
  • 18-24
  • 25-34
  • 35-44
  • 45-54
  • 55-64
  • 65+
  • Prefer not to say
Q14
Multiple Choice

What is your gender identity?

  • Woman
  • Man
  • Non-binary
  • Prefer not to say
Q15
Message

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.

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

  • Includes a dedicated safety screening question on self-harm/suicidal ideation paired with an immediate crisis-resource message, not just a generic health disclaimer.
  • Combines structured symptom-frequency tracking (matrix) and emotional well-being rating with an open-ended narrative question, then uses an AI follow-up interview to explore the client's top-ranked counseling goal and their own account of what's going on in more depth than checkboxes or a single text box could.
  • Captures prior counseling history, preferred session format, and ranked goals so the intake informs both clinical context and logistics before the first appointment.
  • Uses consent and closing chat messages to set expectations and reassure the client their counselor will review responses before the session, framing the intake as part of the therapeutic relationship rather than paperwork.

Jotform

Counseling Intake Form Template

A ready-to-field static form covering standard counseling intake fields like contact info, presenting concerns, and history. It's a traditional form builder template, easily customizable with widgets and e-signature, but it doesn't adapt the questioning based on what a client actually writes.

What it does well

  • Fielding-ready template with drag-and-drop customization
  • Supports e-signature and file upload widgets common in intake paperwork
  • Broad template library suggests easy integration with existing clinic workflows

Where it falls short

  • No adaptive AI follow-up to probe a client's presenting concerns or goals beyond fixed fields
  • No automated per-response quality scoring or clinician-facing report generation
  • No voice AI interview option for clients who prefer speaking over typing

Typeform

Counseling Intake Form Template

A conversational, one-question-at-a-time intake template that likely feels warmer than a typical PDF-style form. It relies on static logic branching rather than true adaptive interviewing, and any deeper exploration of a client's narrative would need to be built manually with conditional logic.

What it does well

  • Polished conversational UI that may reduce intake friction for clients
  • Logic/branching capability for basic personalization
  • Strong design and mobile-friendly presentation

Where it falls short

  • No AI-driven follow-up questions that adapt to a client's actual written answers
  • No built-in safety-screening-to-crisis-resource flow described
  • No transparent prompt methodology or automated clinical report generation

SurveyMonkey

Client Intake Form Template

A generic client intake template aimed at businesses broadly rather than therapy/counseling practices specifically, so it would need significant customization for clinical use (symptom checklists, safety screening, etc.). It's a fielding-ready survey but static in structure.

What it does well

  • Established survey platform with solid reporting/analytics dashboards
  • Easy to customize question types for general intake needs
  • Wide familiarity among respondents

Where it falls short

  • Not counseling-specific out of the box — lacks clinical elements like symptom frequency matrices or safety screening
  • No adaptive AI interview to explore a client's own account of their concerns
  • No voice AI interview or guided screen-share task options

SurveySparrow

Sample client intake form template

A general-purpose, printable-leaning client intake template for businesses rather than a counseling-specific tool; useful as a starting structure but would require substantial rework to cover clinical safety screening and presenting-concern nuance. It's a static template, not an adaptive interview.

What it does well

  • Conversational survey format similar to chat-style intake
  • Printable/exportable option convenient for offline paperwork workflows
  • Simple setup for general business client intake

Where it falls short

  • Not tailored to therapy/counseling contexts (no safety screening or symptom tracking shown)
  • No AI follow-up interview or adaptive probing of client responses
  • No automated quality scoring or clinician-facing report generation

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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