Form templates / Mental Health & Therapy
Child Therapy Intake Form
A child therapy intake form is completed by a parent about a child, which makes it two perspectives at once. What the adult is worried about, and what the child is actually experiencing.
For therapists, counsellors and mental-health practices.
Ask what the child has been told
Children arrive at first sessions having been told anything from the truth to nothing at all - and occasionally that they're going to see someone because they've been naughty. What the child believes is happening shapes the whole first meeting.
So this template asks the parent directly, along with whether the child knows the referral was made and how they feel about coming. It also asks who holds parental responsibility and whether both parents consent, which is a question that becomes very expensive to have skipped.
Why ask it all up front
Half-finished information is worse than none: it looks like you can begin, and then you can't. A client who fills in one page has told you enough to quote, schedule and prepare - without a single back-and-forth.
It also sets the tone. A form that asks precisely, and only once, reads as a business that has done this before. That impression is doing real work while your competitor is still emailing "quick question".
Ask gently, and hold it carefully
A first contact form in this field is often written by someone who has been putting it off for months. Short, plain and unintimidating matters more than thorough - you can ask the rest once there's a relationship.
What it must not do is feel surveilled. These pages carry no analytics, no third-party scripts and no cookie banner, and responses go only to the address you nominate.
It works on a phone, on a bad signal
People fill these in from a car park, a waiting room, a sofa at 11pm. This form is one small page that opens the instant they tap the link and submits without needing anything clever in their browser - so an answer sent on two bars still reaches you.
One minute to make it your own
Every label, option and placeholder on this template is editable, and you can add whatever this template doesn't ask. Save to publish, share the link, and export the responses whenever you need them in a spreadsheet.
What this template asks
- Child's name
- Date of birth
- Your name
- Your relationship to the child
- Email address
- Phone number
- Address
- What are you most concerned about?
- Tell us what you've noticed
- How long has it been going on?
- Did anything happen around the time it started?
- School and year group
- Does school know?
- Is any support already in place?
- What is your child good at, or does she or he enjoy?
- Who's at home?
- Medical conditions and medication
- Has your child ever harmed themselves or talked about not wanting to be here?
- Is there any current involvement from social services?
- Do you hold parental responsibility?
- Does the other parent know about this referral?
- Does your child know about the referral?
- What have you told your child about coming?
- I consent to my child receiving an assessment
More Mental Health & Therapy forms
Questions
Do both parents need to consent?
In most jurisdictions anyone with parental responsibility can consent, but where parents are separated it's usually best practice to have both informed. Ask on the form and follow your professional body's guidance.
How much detail should a parent give in advance?
Enough to plan the first session safely, not a full history. Say that on the form - parents will otherwise write ten pages or two lines, and neither helps.
Can I add or remove questions?
Yes - every question here is a starting point. Add your own, delete what doesn't apply, reorder by dragging, and make anything required or optional. Saving publishes the change immediately.
Where do the answers go?
Into your dashboard, where you can read, filter and export them as a spreadsheet. You can also have every response emailed to you the moment it arrives, or as a daily or weekly digest.
Do I need a website?
No. Every form gets its own link you can paste into an email signature, a text message, a QR code or a social profile. If you do have a site, you can link to it from anywhere on it.
Is this confidential enough for therapy enquiries?
Pages are encrypted in transit and responses stay in your account, going only to the recipients you choose. Keep the form to what you need to make contact, say clearly that it is not for emergencies and where to go instead, and check your professional body's guidance on electronic records.
Publish your child therapy intake form today
Start from this template and change anything you like. Free to begin.