Mental Health Therapist Intake Form Template

We wanted to share our “vanilla” mental health provider intake form with our community.  If you find this page useful, consider sharing it as a resource with a colleague needing help starting their own private practice.

Below in PDF and Doc file formats is our intake form.  We have our slightly modified for the providers we work with in our billing service, but this is a great one to utilize in your private practice, especially if you take insurance.

Our document helps you collect demographic information like:

  • Full Name
  • Gender
  • Date of Birth
  • Address

And essential insurance information such as:

  • Insurance company name
  • Client’s subscriber ID (with all letters / prefixes / postfixes)
  • The provider customer service phone number on the back of the card, or the mental health customer service number, if indicated on the card

Download the PDF copy of our intake form for mental health providers:

Download your Word doc / docx copy of our mental health intake form here:

Quick Intake Tip!

If you have a new patient, take out your smart phone or digital camera and snap the front and back of their card.  You don’t need to do anything with it unless you need it, but if you do need it, you’ll have that information.  Often times folks can give you slightly incorrect or hard to read information.  A copy of their insurance card is very helpful to have on file.

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If you appreciated this useful document, please consider sharing our intake form page on Facebook, Twitter, or via Email.  Hoping we can help!

-Denny & The Team @ TheraThink

See Our Mental Health Provider Intake Form Embedded Below:


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“As private practitioners, our clinical work alone is full-time. Add in the unnecessarily difficult insurance billing system and we run the risk of working way over full-time. TheraThink, Inc provides an affordable and incredibly easy solution. My daily insurance billing time now is less than five minutes for a full day of appointments. My cost is a percentage of what is insurance-approved and it’s my favorite bill to pay each month! Denny and his team are responsive, incredibly easy to work with, and know their stuff. I cannot capture in words the value to me of TheraThink. Thank you. You free me to focus on the work I love!”

Thank you so very much Denny…. Ahhh insurance companies 🙂 I’m thankful for all you and your team does. I am so happy that you always do such great work and I enjoy the peace of mind you and your team provides me 🙂 Happy Monday!

It’s a joy working with you all and a complete breath of fresh air!!