Capture intake basics
Required: name, phone, areas of concern (multi-select: anxiety / depression / couples / trauma / family / etc.), insurance carrier or 'private pay / sliding scale', telehealth vs in-person preference.
Form template · Free consultation
Therapist Contact Form Template
Therapy inquiries are vulnerable — the form needs to feel safe. Capture the basics (areas of concern, insurance, modality preference) without forcing trauma details before the first session.
- 500 free total
- No PHP · no SDK
- One POST endpoint
Live template preview
Free consultation
Full name *Tomás López
Email *tomas@example.com
Phone *+1 555 0184
Topic *General inquiry
What do you need help with? *Be specific so we can match you with the right advisor.
Send
This template is one of our free HTML form templates. See more form templates by industry. Choosing a form setup for your clinic? Read the guide: Best Contact Form for Clinics (2026): Options by Use Case.
Pick your therapist contact form — one click to use it
Every template is free and fully editable in the drag-drop builder — swap fields, colors, and the button label before you publish.
Best matchUse this template
Therapist Contact Form Template
Free consultation
Full name *Tomás López
Email *tomas@example.com
Phone *+1 555 0184
+ 2 more fields in the builder
Send
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Email *patient@example.com
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Your name *Jane Builder
Email *jane@example.com
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No backend code
No server, API route, or SDK — your Therapist Contact Form posts straight to one endpoint.
Straight to your inbox
Every submission is emailed to you and saved to a searchable dashboard — spam filtered before it reaches you.
Copy-paste ready
It's plain HTML you own — paste the Therapist Contact Form snippet, swap in your access key, and ship.
Copy and ship
Your Therapist Contact Form, ready to paste.
HTML by default — the same field set also renders as React, Next.js, PHP, and cURL in your dashboard. Every variant posts to the same /api/submit endpoint. Replace YOUR_ACCESS_KEY with the key from your dashboard; that's the only edit.
<form action="https://splitforms.com/api/submit" method="POST">
<input type="hidden" name="access_key" value="YOUR_ACCESS_KEY">
<input type="hidden" name="subject" value="New consultation request">
<label for="name">Full name *</label>
<input id="name" type="text" name="name" placeholder="Tomás López" required>
<label for="email">Email *</label>
<input id="email" type="email" name="email" placeholder="tomas@example.com" required>
<label for="phone">Phone *</label>
<input id="phone" type="tel" name="phone" placeholder="+1 555 0184" required>
<label for="topic">Topic *</label>
<select id="topic" name="topic" required>
<option value="">Choose…</option>
<option>General inquiry</option>
<option>Strategy</option>
<option>Financial planning</option>
<option>Legal advice</option>
<option>Other</option>
</select>
<label for="details">What do you need help with? *</label>
<textarea id="details" name="details" placeholder="Be specific so we can match you with the right advisor." required></textarea>
<!-- honeypot — bots fill every field -->
<input type="checkbox" name="botcheck" style="display:none" tabindex="-1" autocomplete="off">
<button type="submit">Send</button>
</form><p class="splitforms-attribution" style="margin-top:12px;font-size:11px;color:#888;text-align:right">
Powered by <a href="https://splitforms.com" style="color:#888;text-decoration:none" target="_blank" rel="noopener">splitforms</a>
</p>
<!-- drop-off analytics + partial leads (the form works without it) -->
<script src="https://splitforms.com/embed.js" async></script>How to add it
How to add this form to your site.
To add a Therapist Contact Form to your site you need three things: a free splitforms access key, the HTML snippet above, and your key pasted into it. No backend, database, or CAPTCHA library — the form posts to one URL and every submission lands in your inbox and dashboard.
Match to specialty and modality
Group practices route by specialty — anxiety to one therapist, couples to another. Solo practices use the field to confirm fit before the consult call. Bad-fit referrals go out same-day with 2-3 colleague names.
Schedule the consult
Auto-respond with a 15-min phone consult booking link (Calendly / SimplePractice). Most therapists offer a free 15-min 'fit check' call before the paid intake session. Reduces session-1 mismatches by 60-70%.
What's included
What's included.
Therapy practices run 50-min sessions at $100-250 (private pay) or insurance-billed at $80-150. Many therapists offer sliding-scale fees ($50-100) for limited slots. No-show rates run 10-15% — high for a service business — so therapists overbook by ~15% and confirm via SMS the day before. The form captures areas of concern (anxiety / depression / couples / trauma / family / substance use), insurance carrier or sliding-scale interest, in-person vs telehealth preference, and a brief 'what brings you here?' textarea. Speed-to-call matters: therapy seekers research carefully then act on impulse — a 24-48 hour reply is standard, but same-day reaches the prospect when the motivation is fresh. Webhooks into SimplePractice / TherapyNotes · not HIPAA compliant, no BAA on any plan.
- Free consultation — 5 ready-made fields
- HTML, JS, React, PHP, and cURL outputs
- One POST endpoint, no SDK — honeypot and spam scoring, no CAPTCHA
Where submissions go
Where submissions go.
Reply-to is wired to the visitor's email, so one tap on Reply answers them directly — while the built-in honeypot and automatic spam scoring filter out bots before they reach you. Every submission is emailed to your inbox and can forward to a webhook or Slack the moment a visitor hits send.
- Reply-to wired to the visitor's email — reply straight from your inbox
- Honeypot and automatic spam scoring filter bots, no CAPTCHA friction
- Live dashboard, CSV export, and signed webhooks on paid plans
How SplitForms works
What happens after someone submits your form?
splitforms receives the submission, filters spam, saves it to your dashboard and emails you — then, on paid plans, sends it on to your webhooks and integrations. No backend infrastructure to build.
Add your endpoint
Point your form to your unique SplitForms endpoint. That's it.
Receive submissions
We instantly capture and organize every submission in your inbox.
Route anywhere
Send data to email, spreadsheets, CRMs, webhooks, and 7,000+ apps.
No credit card required. Set up in under 60 seconds.
Connect & automate
Where can submissions go besides email?
On paid plans, submissions can also go to Slack, Discord, Google Sheets, Notion, Airtable, Zapier or any signed webhook — and splitforms works on the platforms you build on, from WordPress and Shopify to Next.js. With Stripe connected, your forms can take payments too.
NewTake payments on your formsDeposits, bookings, order forms — submitters check out through Stripe and the money goes straight to your Stripe account. Included on every paid plan.See payment forms →Need time slots? Online booking →Questions
Frequently asked questions.
View all FAQsIs splitforms HIPAA-compliant for therapy intake?
No. splitforms is not HIPAA compliant and signs no BAA on any plan. For HIPAA-compliant intake collecting protected health information (PHI), use SimplePractice, TherapyNotes, or JotForm's HIPAA tier. The splitforms form is fine for the public-facing 'request a consult' step (name, phone, general areas of concern) — keep the detailed intake on the HIPAA platform once they book. Consult your HIPAA officer.
Can I integrate with SimplePractice / TherapyNotes / TheraNest?
All three EHR-grade therapy CRMs accept inbound leads via Zapier or webhook. The lead lands as a prospective client; the formal intake (PHI) happens inside the platform's secure portal, not on the splitforms form. Two-stage funnel keeps you on the right side of HIPAA.
How do I handle sliding-scale slot allocation?
Add a 'how do you plan to pay?' radio: insurance / private pay / sliding-scale request. Sliding-scale requests get a 'we have limited slots and will reach out if available' auto-response. Most therapists hold 10-20% of caseload for sliding-scale; the field manages expectations honestly.
What about emergency / crisis cases?
The form should explicitly state: 'this form is not for emergencies. If you're in crisis, call 988 (Suicide & Crisis Lifeline) or 911.' Liability requires that disclaimer prominently above the form. Most therapists also add 'I am not currently in crisis' as a required confirmation checkbox.
Simple pricing
How much does splitforms cost?
Free gives you 500 submissions for $0 — no card, no time limit. Pro is $5/month for 5,000 submissions a month, and Annual is $49/year for 15,000 a month with every Pro feature.
Free
$0— 500 submissions
For side projects and indie devs.
- 500 free submissions
- Unlimited forms
- Email notifications included
- Smart spam filtering
- Submissions dashboard
- Redirect after submit
- MCP server included
Recommended
Pro
$5/ month
Billed monthly
Every paid feature, for agencies and growing products.
- 5,000 submissions per month
- Unlimited forms
- Webhooks and integrations
- CC/BCC, auto-replies and routing
- File uploads with 500 MB storage
- Stripe payments on your forms
- 3 team seats
- Cancel anytime
Annual
$49/ year
About $4.08 per month, billed yearly
Every Pro feature with triple the volume — $0.27 per 1,000 at full use.
- 15,000 submissions per month
- Unlimited forms
- Everything in Pro
- File uploads with 5 GB storage
- 3 team seats
- Priority email support
No credit card required on Free • Cancel anytime • Full pricing and FAQ