Art Therapy Client Intake Form
Full Name
Date of Birth
Phone Number
Email
Address
Emergency Contact Name
Emergency Contact Phone
Relationship to Emergency Contact
How did you learn about art therapy?
What are your reasons for seeking art therapy?
Have you participated in art therapy or counseling before?
Yes
No
If yes, please specify and describe your experience:
Current medical or mental health concerns
Are you currently taking any medications?
Yes
No
If yes, please list:
Any allergies or special needs?
Is there anything else you'd like your art therapist to know?