Client Intake Form Template UK

The Client Intake Form Template UK is offered in multiple formats, including PDF, Word, and Google Docs, featuring customizable and printable samples to suit your needs.

Open – Template

Online – Template

Sample

Client Intake Form Template UK

Editable – Printable

PDF – 1 PDF – 2

Client Intake Form Template UK

1. Client Information




2. Emergency Contact Information



3. Health Information

4. Previous Treatment History

5. Current Medications

6. Reason for Intake

7. Referral Source

8. Consent Information

9. Additional Information

10. Declaration and Consent


PDF

WORD

Examples

Client Intake Form Template UK (1)
Client Information:
Full Name: [Client’s Full Name]
Date of Birth: [Client’s Date of Birth]
Phone Number: [Client’s Phone Number]
Email Address: [Client’s Email Address]
Address: [Client’s Address]
Emergency Contact:
Full Name: [Emergency Contact Name]
Relationship: [Relationship to Client]
Phone Number: [Emergency Contact Phone Number]
Referral Source:
How did you hear about us? [Referral Source]
If referred by a person, please provide their name: [Referrer’s Name]
Purpose of Consultation:
Please briefly describe the reason for your visit: [Description of Purpose]
Medical History:
Do you have any pre-existing conditions? [Yes/No]
If yes, please specify: [Detailed Conditions]
Current Medications:
Please list any medications you are currently taking: [Medication List]
Insurance Information:
Provider Name: [Insurance Provider Name]
Policy Number: [Insurance Policy Number]
Group Number: [Insurance Group Number]
Consent:
I hereby authorize the release of medical information necessary to process my treatment and insurance claims.
Signature: [Client’s Signature]
Date: [Date]
Client Intake Form Template UK (2)
Client Information:
Full Name: [Client’s Full Name]
Date of Birth: [Client’s Date of Birth]
Contact Number: [Client’s Phone Number]
Email Address: [Client’s Email Address]
Residential Address: [Client’s Address]
Emergency Contact:
Full Name: [Emergency Contact Name]
Relation to Client: [Relation]
Contact Number: [Emergency Contact Phone Number]
How Did You Find Us?
Please indicate how you heard about our services: [Source]
If you were referred, please tell us who referred you: [Referrer’s Name]
Reason for Visit:
Briefly describe the reason for your appointment: [Purpose Description]
Medical Background:
Do you have any past medical conditions? [Yes/No]
If yes, please list them: [List of Conditions]
Current Medications:
List any medications you are currently on: [Medication Details]
Insurance Details:
Insurance Company: [Insurance Company Name]
Policy Number: [Insurance Policy Number]
Group Number: [Insurance Group Number]
Consent Acknowledgment:
I consent to the use of my medical information for the purpose of treatment and insurance processing.
Signature: [Client’s Signature]
Date: [Date]

Printable

PDF – 1 PDF – 2

Client Intake Form Template UK