Start Intake | Inner Door Therapy

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New Client Intake

First name

Last name

Phone

Birthday

Month

Day

Year

Multi-line address

Country/Region

Address

Address - line 2

City

Zip / Postal code

Preferred pronouns

What brings you to counseling/therapy at this time?

How long have these concerns or symptoms been going on?

Have you been in therapy or counseling before? If yes, what was helpful or unhelpful?

Current physical health conditions, major medical history, or recent medical changes:

Current prescription medications and supplements:

Do you have a history of mental health diagnoses, psychiatric hospitalizations, or substance use concerns?

What would you like to be different three months from now?

How would you describe your current support system (family, friends, community)?

Is there anything else you want your provider to know before your first session?

Privacy & Privacy Policy Notice: Your information is confidential and protected under HIPAA regulations. By submitting this form, you consent to our privacy policy and the collection of data for the purpose of initiating counseling services.

Confidentiality & Privacy

Your trust is our priority. All information shared through this intake form is encrypted and handled in strict accordance with HIPAA standards. We use your data solely to coordinate your care and connect you with the right trauma specialist. We never sell or share your personal information with third parties for marketing purposes.