Client Intake

Full name Please fill in this field.

Credentials (after your name)e.g. LCSW, PhD, LPC

Email Please fill in this field.

Phone Please fill in this field.

Practice name, if you have one

Licensed in (state(s))

Practice structure

Is this for a private practice, or a different type of program?

Private practice Intensive program IOP Other

Which package are you considering for your site?

Current Online Presence

Directory profile linkse.g. Psychology Today, Headway, OK Clarity, etc. Paste any that apply.

Existing website, if any

Do you have an existing bio somewhere? If so, paste it below.

Clinical Orientation

What frameworks do you draw on?What type of therapy do you offer? For example: CBT, IFS, psychodynamic, DBT, etc.

Education & training backgroundWhere you got your degree, year you graduated, any postgrad training programs, certifications.

Gender of clients you work with

Males Females Both Other

How would you describe your practice and the type of therapy you do, in your own words?If it's easier, feel free to send a voice note on WhatsApp instead.

Practice Details

Session format

Location of office for in-person sessions, if you have onewhat town or locality

Do you want your office address listed on the site, or just a general service area?

List my full office address Just show a general service area Other

If you would like the address listed, please type it hereleave blank if not

Standard session length

Session fee or range

Sliding scale?

Yes No Yes, limited spots Other

Insurance

Out of pocket only (private pay) In-network (insurance panels) Other

Insurance detailwhich plans, or any notes on your fee policy. Common plans include: Aetna, Blue Cross Blue Shield, Cigna, UnitedHealthcare, Humana, Kaiser Permanente.

Do you currently use an EHR (electronic health record) system?

Do you have a public scheduling link you want on the website?for clients to schedule a free 15-minute intro call or consultation. If so, paste it here.

Do you already have a professional email set up, or would you be interested in Google Workspace?

I already have a professional email set up I would be interested in getting set up with Google Workspace Not sure yet Other

Preferred contact method on the site

Design Preferences

What's your overall vision for the site, if you have one?Look, feel, content, structure — whatever comes to mind.

Sites you likeany websites you find appealing and would want to emulate in some way (paste URLs) Don't have any specific sites in mind? Check out this list of examples.

What about the site(s) you liked would you want to bring into yours?

Overall vibe or aesthetic Color choices Design elements Site structure and sections Something else (please specify)

Do you have any specific copy already written that you want on the site?This can include writing for various sections, taglines, or headlines.

How would you like me to be in touch with you?