Cognitive Behavioral Therapy (CBT) Intake Form
Personal Information
Full Name
Date of Birth
Address
Phone Number
Email Address
Emergency Contact
Name
Phone
Relationship
Referral Information
How did you hear about CBT services?
Presenting Concerns
Please describe your main reasons for seeking CBT:
How long have these concerns been present?
What triggers, if any, have you noticed?
Relevant History
Briefly describe any previous mental health treatment:
Significant medical conditions or medications:
Family history of mental health concerns:
Additional Information
What are your goals for therapy?
Is there anything else you would like your therapist to know?