Amputation Adjustment Therapy Intake Form

Adjusting to limb loss is a deeply personal journey that involves physical, emotional, and psychological adaptation. This Amputation Adjustment Therapy Intake Form is designed for mental health professionals, counselors, and therapists who specialize in supporting individuals through the complex process of adapting to amputation.

Whether you're a therapist in private practice, part of a rehabilitation center, or working within a hospital setting, this template helps you gather essential information about your client's amputation circumstances, current challenges, and therapeutic goals in a sensitive and structured way.

What makes this form valuable for mental health professionals:

The form captures critical details about the type and timing of amputation, phantom limb pain experiences, prosthetic use and adaptation, body image concerns, and emotional adjustment. It includes questions about mobility changes, social support systems, and specific therapeutic goals—giving you a comprehensive picture before your first session.

Built with Paperform, this intake form can be customized to match your practice's brand and workflow. Use conditional logic to show relevant follow-up questions based on amputation type or pain levels, ensuring clients only see questions that apply to their situation. The form integrates seamlessly with your practice management software, CRM, or Google Sheets to keep client records organized.

Streamline your practice with automation:

After a client submits their intake form, you can use Stepper (stepper.io) to automatically send appointment confirmation emails, create calendar events, generate personalized welcome packets, or trigger internal notifications to your admin team. This automation ensures nothing falls through the cracks while you focus on providing compassionate care.

For practices requiring signed consent forms or HIPAA acknowledgments, you can follow up with Papersign (papersign.com) to send secure eSignature requests directly linked to the intake submission, creating a complete digital onboarding experience.

This template is ideal for therapists, psychologists, counselors, social workers, occupational therapists, and rehabilitation specialists who work with amputees. It's designed to create a safe, welcoming first impression while gathering the clinical information you need to provide effective, personalized support.