[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"detail-sidebar-cat-1-en-105":3,"doc-seo-307617-105":53,"doc-detail-307617-en":126},{"code":4,"msg":5,"data":6},0,"success",[7,14,19,24,29,34,39,44,49],{"id":8,"doc_module":9,"doc_module_name":10,"category_name":11,"show_sort_weight":12,"slug":13},11,1,"Template","Presentations",90,"presentations",{"id":15,"doc_module":9,"doc_module_name":10,"category_name":16,"show_sort_weight":17,"slug":18},12,"Resumes",80,"resumes",{"id":20,"doc_module":9,"doc_module_name":10,"category_name":21,"show_sort_weight":22,"slug":23},14,"Invoices",70,"invoices",{"id":25,"doc_module":9,"doc_module_name":10,"category_name":26,"show_sort_weight":27,"slug":28},15,"Posters",60,"posters",{"id":30,"doc_module":9,"doc_module_name":10,"category_name":31,"show_sort_weight":32,"slug":33},16,"Social Media",50,"social-media",{"id":35,"doc_module":9,"doc_module_name":10,"category_name":36,"show_sort_weight":37,"slug":38},17,"Forms",40,"forms",{"id":40,"doc_module":9,"doc_module_name":10,"category_name":41,"show_sort_weight":42,"slug":43},18,"Letters",30,"letters",{"id":45,"doc_module":9,"doc_module_name":10,"category_name":46,"show_sort_weight":47,"slug":48},21,"Paper Templates",5,"papers-templates",{"id":50,"doc_module":9,"doc_module_name":10,"category_name":51,"show_sort_weight":4,"slug":52},158,"General","general-158",{"code":4,"msg":54,"data":55},"ok",{"site_id":56,"language":57,"slug":58,"title":59,"keywords":60,"description":61,"schema_data":62,"social_meta":119,"head_meta":121,"extra_data":123,"updated_unix":125},105,"en","therapy-intake-form-template","Therapy Intake Form Template","","Therapy Intake Form Template collects essential patient information for behavioral and mental health services, including demographics, contact details, emergency contact, and preferred communication options. It gathers medical history and current medications, primary care physician and psychiatrist details, insurance information, employment status, and weekly availability. Additional sections assess personal and family mental health history, hospitalization, substance use, arrests, suicide attempts, and functioning in work, relationships, and overall wellbeing, followed by patient/guardian attestation and signature.",{"@graph":63,"@context":118},[64,80,101],{"@type":65,"itemListElement":66},"BreadcrumbList",[67,71,74,77],{"item":68,"name":69,"@type":70,"position":9},"https://docshare.wps.com","Home","ListItem",{"item":72,"name":10,"@type":70,"position":73},"https://docshare.wps.com/template/",2,{"item":75,"name":36,"@type":70,"position":76},"https://docshare.wps.com/template/forms/",3,{"item":78,"name":59,"@type":70,"position":79},"https://docshare.wps.com/template/therapy-intake-form-template/307617/",4,{"url":78,"name":59,"@type":81,"image":82,"author":87,"headline":59,"publisher":90,"fileFormat":93,"inLanguage":57,"description":61,"dateModified":94,"datePublished":95,"encodingFormat":93,"isAccessibleForFree":96,"interactionStatistic":97},"DigitalDocument",{"url":83,"@type":84,"width":85,"height":86},"https://docshare.wps.com/thumbnails/therapy-intake-form-template/307617.png","ImageObject",442,249,{"name":88,"@type":89},"Stanford","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-10-24","2026-09-19",true,{"@type":98,"interactionType":99,"userInteractionCount":20},"InteractionCounter",{"@type":100},"ViewAction",{"@type":102,"mainEntity":103},"FAQPage",[104,110,114],{"name":105,"@type":106,"acceptedAnswer":107},"What patient details does the therapy intake form request?","Question",{"text":108,"@type":109},"It requests first and last name, preferred name, patient identifier (if known), gender, preferred pronouns, date of birth, marital status, address, email, and preferred phone number, plus emergency contact information.","Answer",{"name":111,"@type":106,"acceptedAnswer":112},"Which medical and treatment history items are included?",{"text":113,"@type":109},"The form includes primary care physician and psychiatrist details, lists for medical conditions and current medications, and insurance-related fields such as plan and policy information.",{"name":115,"@type":106,"acceptedAnswer":116},"What mental health and risk screening questions are asked?",{"text":117,"@type":109},"It asks about ethnicity, household size, income level, education, psychiatric hospitalization, family history of mental illness and substance abuse, suicide attempts (personal and in family), arrests with explanation if applicable, and several functioning and wellbeing self-ratings.","https://schema.org",{"og:url":78,"og:type":120,"og:title":59,"og:site_name":91,"og:description":61},"article",{"robots":122,"canonical":78},"index,follow",{"doc_id":124,"site_id":56},307617,1790250000,{"code":4,"msg":5,"data":127},{"doc_id":124,"user_id":128,"nickname":88,"user_avatar":129,"doc_module":9,"category_id":35,"category_name":36,"doc_title":59,"doc_description":61,"doc_content":130,"file_id":131,"file_url":132,"file_type":133,"file_size":134,"view_count":20,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":73,"language":135,"language_code":57,"site_id":56,"html_lang":57,"table_of_contents":136,"faqs":137,"seo_title":138,"seo_description":61,"update_tm":139,"read_time":9},2336477552062,"https://ap-avatar.wpscdn.com/davatar_994ba38a5ba835b3df7d355c54d3ed8d","# Therapy Intake Form Template\n\n\n| Patient Information   |  |  |  |  |  |  |  |  |  |  |\n| --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- |\n| First Name   |  | Last Name   |  |  | Preferred Name   |  |  |  | Patient Identifier(If known)   |  |\n| Gender   | Preferred Pronouns   |  |  | Date of Birth   |  |  |  | Marital Status   |  |  |\n| Address   |  |  |  |  |  | City   |  | State   |  | Zip Code   |\n| Email   |  |  |  |  | Preferred Phone Number   |  |  |  |  |  |\n| Emergency Contact   |  |  |  |  |  |  |  |  |  |  |\n| Full Name   |  |  | Relationship   |  |  |  | Contact Number   |  |  |  |\n| Full Name   |  |  | Relationship   |  |  |  | Contact Number   |  |  |  |\n| Health and Medical Information   |  |  |  |  |  |  |  |  |  |  |\n| Primary Care Physician   |  |  | Address   |  |  |  | Contact Number   |  |  |  |\n| Psychiatrist   |  |  | Address   |  |  |  | Contact Number   |  |  |  |\n| Please list any medical conditions   |  |  |  |  |  |  |  |  |  |  |\n| Please list any current medication   |  |  |  |  |  |  |  |  |  |  |\n| Insurance Information (If Applicable)   |  |  |  |  |  |  |  |  |  |  |\n| Insurance Carrer   |  |  | Insurance Plan   |  |  |  | Contact Number   |  |  |  |\n| Policy Number   |  |  | Group Number   |  |  |  | Social Security Number   |  |  |  |\n| Employment Status   |  |  |  |  |  |  |  |  |  |  |\n| OEmployed  \u003Cbr>OSelf Employed  \u003Cbr>Oother_  \u003Cbr>OUnemployed   |  |  |  |  |  |  |  |  |  |  |\n| Occupation   |  |  | Industry   |  |  |  | Company Name   |  |  |  |\n| Company Address   |  |  |  |  |  | City   |  | State   |  | Zip Code   |\n| Availability   |  |  |  |  |  |  |  |  |  |  |\n| Please describe your availability throughout the week   |  |  |  |  |  |  |  |  |  |  |\n\nPowered by  \nhttp://Carepatron.com  \n\n| Patient Information   |  |  |  |  |\n| --- | --- | --- | --- | --- |\n| First Name   | Last Name   |  | Date of Birth   | Gender   |\n| Personal and Family   |  |  |  |  |\n| What is your ethnicity?   |  |  |  |  |\n| How many people are in your household?   |  |  |  |  |\n| What is your income level?   |  |  |  |  |\n| What is the highest education level you've completed?   |  |  |  |  |\n| □Yes □No  \u003Cbr>Have you ever been hospitalized for a psychiatric illness?   |  |  |  |  |\n| □Yes □No  \u003Cbr>Does any family members have a history of mentalillness?   |  |  |  |  |\n| □Yes □No  \u003Cbr>Have you ever attempted suicide?   |  |  |  |  |\n| □Yes □No  \u003Cbr>Has any family members ever attempted or committed suicide?   |  |  |  |  |\n| □Yes □No  \u003Cbr>Do you have problems with substance abuse?   |  |  |  |  |\n| □Yes □No  \u003Cbr>Does any family members have problems with substance abuse?   |  |  |  |  |\n| □Yes □No  \u003Cbr>Have you ever been arrested?  \u003Cbr>If yes,please explain:   |  |  |  |  |\n| How are you doing at your job?  \u003Cbr>□I.Not working □II.Cannot Function □I.Serious Problem □IV.Mild Problem □V.No Problem  \u003Cbr>How are you doing at in your marital or with your significant other?  \u003Cbr>□I.Not working □II.Cannot Function □I Serious Problem □IV.Mild Problem □V.No Problem  \u003Cbr>How are you doing in relationships with family member?  \u003Cbr>□I.Not working □II.Cannot Function □I Serious Problem □IV.Mild Problem □V.No Problem  \u003Cbr>How are you doing in relationships with non-family member?  \u003Cbr>□I.Not working □II.Cannot Function □I.Serious Problem □IV.Mild Problem □V.No Problem  \u003Cbr>How is your overall happiness and well-being?  \u003Cbr>□I.Not working □II.Cannot Function □I Serious Problem □IV.Mild Problem □V.No Problem   |  |  |  |  |\n| All the answers given to the above questions are answered accurately to the best of my knowledge.I understand that  \u003Cbr>any inaccurate information can be dangerous to my(or patient's)health.   |  |  |  |  |\n| Parent or Guardian Name (lf Applicable)   |  | Relationship to Patient (If Applicable)   |  |  |\n| Signature of Patient,Parent or Guardian   |  | Date   |  |  |\n\nPowered by","cbCaiuc0sUX6Rqyy","https://ap.wps.com/l/cbCaiuc0sUX6Rqyy","pdf",909983,"English","# Patient Information\n# Health and Medical Information\n# Insurance Information\n# Employment and Availability\n# Personal and Family Screening\n# Attestation and Signatures","[{\"question\":\"What patient details does the therapy intake form request?\",\"answer\":\"It requests first and last name, preferred name, patient identifier (if known), gender, preferred pronouns, date of birth, marital status, address, email, and preferred phone number, plus emergency contact information.\"},{\"question\":\"Which medical and treatment history items are included?\",\"answer\":\"The form includes primary care physician and psychiatrist details, lists for medical conditions and current medications, and insurance-related fields such as plan and policy information.\"},{\"question\":\"What mental health and risk screening questions are asked?\",\"answer\":\"It asks about ethnicity, household size, income level, education, psychiatric hospitalization, family history of mental illness and substance abuse, suicide attempts (personal and in family), arrests with explanation if applicable, and several functioning and wellbeing self-ratings.\"}]","Therapy Intake Form Template | PDF",1789851995]