Art Therapy Intake Assessment
Personal Information
Client Name
Date of Birth
Address
Phone Number
Email
Emergency Contact
Referral Information
Referral Source
Reason for Referral
Presenting Concerns
Presenting Concerns
Goals for Art Therapy
Medical & Mental Health History
Relevant Medical/Psychiatric History
Current Medications
Other Treatments/Support
Previous Art Therapy Experience
Previous Experience with Art or Art Therapy
Preferred Art Materials/Methods
Additional Information
Personal Strengths
Other Notes