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 / mo
- 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
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
Free consultation
Full name *Tomás López
Email *tomas@example.com
Phone *+1 555 0184
+ 2 more fields in the builder
Send
Doctor appointment
Patient name *Daniel Chen
Email *patient@example.com
Phone *+1 415 555 0142
+ 4 more fields in the builder
Send
Dental appointment
Patient name *Daniel Chen
Email *daniel@example.com
Phone *+1 555 0142
+ 6 more fields in the builder
Send
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="sponsored noopener">splitforms</a>
</p>How to add it
How to add a Therapist Contact 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 in this Therapist Contact Form template?
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 out of the box.
- Free consultation — 5 ready-made fields
- HTML, JS, React, PHP, and cURL outputs
- One POST endpoint, no SDK — honeypot and classifier, no CAPTCHA
Where submissions go
Where do your Therapist Contact Form 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 spam classifier 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 spam classifier filter bots, no CAPTCHA friction
- Live dashboard, CSV export, and signed webhooks on paid plans
How SplitForms works
From form to workflow in 3 simple steps.
Connect your form, collect every submission, and send data where it needs to go — without building backend infrastructure.
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.
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SplitForms works with the destinations you route to and the platforms you build on — from Slack and Sheets to WordPress, Shopify, and Next.js.
Trusted by indie teams and agencies shipping forms worldwide
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Testimonials
Loved by developers shipping at every scale.
40 quotes on record — from indie hacks to agency migrations.
“I replaced a Lambda + DynamoDB + SES contact form with six lines of HTML. It took eleven minutes, and the dashboard is better than what I was going to build.”
“We migrated 14 client sites off Formspree in a single weekend. The price is a third of what we paid, the API is more honest, and the spam filter actually works.”
“The webhook payload is signed, idempotent, and well-shaped. It reads like code from a competent team, not a CRUD app held together with duct tape.”
“I stopped reaching for Typeform on small marketing sites. splitforms covers 90% of the use case at none of the bloat.”
“I onboarded our whole agency in an afternoon. The MCP integration meant Cursor literally dropped the form straight into our client repos for us.”
“The free plan gave me 500 submissions before I paid a cent, and Pro is five dollars a month. I've spent more on coffee deciding which backend to use.”
“Spam went from forty junk entries a day to zero, with no reCAPTCHA puzzle ruining the form. The honeypot and time-trap just quietly do their job.”
“Point the form action at one endpoint and you're done. No SDK, no client library, no build step. This is how a form backend should feel.”
“Leads land in Slack the second someone submits, and a copy goes to Google Sheets for the sales team. I wired both up in under ten minutes.”
“I run a static Hugo site on a five-dollar VPS. splitforms gave it a real contact form without me standing up a single server.”
Questions
Therapist Contact Form questions.
View all FAQsIs splitforms HIPAA-compliant for therapy intake?
Not out of the box — no BAA on the standard 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
Start free. Scale when you need more.
Choose a plan that fits your workflow — from a free form endpoint to full automations, exports, and higher submission limits.
Free
$0
Free forever
For side projects and indie devs.
- 500 submissions / mo
- Unlimited forms
- Email notifications included
- Honeypot spam filtering
- Submissions dashboard
- MCP setup stays free
- No credit card required
Most Popular
Pro
$5/ month
was $15 · save 67% · new-user price
For agencies and growing products.
- 5,000 submissions / mo
- Unlimited forms
- Every paid feature included
- Priority support (under 4hr)
- 10× free submission volume
- Cancel anytime
Pre-launch · founders pricing locked in
3-Year
$59/ 36 months
was $99 · save 40% · new-user price
Pay $59. 3 years sorted.
- 15,000 submissions / mo
- Unlimited forms
- Everything in Pro
- Renews every 3 years
- Long-term discount
- Priority support included
- Vote on the roadmap
No credit card required on Free • Cancel anytime