Mental Health Intake Form

Mental Health Intake Form
Patient name

First NameLast Name
Patient date of birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Who should form be sent to/who is your appointment with?
Form completed by/Relationship to patient
Please list the reason for your visit/referral today
Current Medications

Psychiatric Medications:

Non-psychiatric Medications (prescription):

Over the counter Medications:

List three most recent counselors/therapists starting with most current:

List any prior medication evaluations:

List any previous medications (no longer being taken)

Illness:

Has your child had any frightening or traumatic experiences? If yes, please describe:

Has your child ever experienced sexual or physical abuse? If yes, please describe:

Has your child ever been a witness to violence? If yes, please describe:

Rows	Click for 'yes'	Details
Witness to domestic violence
Witness to other violence

Substance

Rows	Yes	No
Have you ever felt the need to cut down on your drinking?
Have you ever felt annoyed by the criticism of your drinking?
Have you ever felt guilty feelings about drinking?
Have you ever taken a morning eye opener?
Have you ever been to a detox program or drug rehab program?

If yes (detox), when and where
Parent's marital history
Would you describe your marital relationship as having:
Separation

Have there been separations of your child from either parent?
Father
Dates
Describe including child's reaction:
Mother
Dates:
Describe including child's reaction:
Was either parent unable or unwilling to care for the child at any time?
Describe reason and child's reaction:
Birth
Labor difficulties:
Comments:
Weight (lb)
Weight (lb)
Weight (oz)
Length (inches)
Location:
Comments:
Postnatal
Medical complications:
Comments:
Feeding:
Postpartum depression for mother:
Slept through the night at age (months):
Developmental milestones
Sat unsupported at:
Crawled at:
Walked at:
Talked - first word at:
Two word phrases:
Toilet trained at (age):
Continues to have difficulties:
Wetting:
Soiling:
Toileting comments (frequency of issues, details):
Early development
To whom is the child primarily attached?
Who else is the child strongly attached to?
Did the child experience a change in caretakers before the age of 3?
Please describe:
How old was the child when they entered daycare/preschool/early intervention or other program?

List specific programs and approximate dates (including full or half-day babysitting):

Current Medications