Mental Health Intake Form

Mental Health Intake Form
Date

MonthDayYear
Date
Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Gender
Primary Care Physician

First NameLast Name
Current Therapist / Counselor

First NameLast Name
Therapist's Phone Number

Area CodePhone Number
Please list the problem(s) which you are seeking help?
Current Symptoms

Depressed moodRacing thoughtsExcessive worryUnable to enjoy activitiesImpulsivityAnxiety attacksSleep pattern disturbanceIncrease risky behaviorAvoidanceLoss of interestIncreased libidoHallucinationsConcentration/forgetfulnessDecrease need for sleepSuspiciousnessChange in appetiteExcessive energyExcessive guiltIncreased irritabilityFatigueCrying spellsDecreased libidoOther
Have you ever had feelings or thoughts that you didn't want to live?

YesNo
Do you currently feel that you don't want to live?

YesNo
How often do you have these thoughts?
When was the last time you had thoughts of dying?

On a scale of 1 to 10, (ten being strongest) how strong is your desire to kill yourself currently?

	1	2	3	4	5	6	7	8	9	10

1 is Weak, 10 is Strong

Rows	Yes	No
Do you feel hopeless and/or worthless?
Have you ever tried to kill or harm yourself before?
Is there anything that would stop you from killing yourself?

If you have ever taken any of the following medications, please indicate the dates and daily dosage.

Other medications?
Family Psychiatric History
Has anyone in your family been diagnosed with or treated for:

Bipolar disorderDepressionAnxietyAngerSuicideSchizophreniaPost-traumatic stressAlcoholabuseOther
Has any family member been treated with a psychiatric medication? If yes, who was treated, what medications did they take, and how effective was the treatment?
Exercise Level
Do you exercise regularly?

YesNo
How much time each day do you exercise?
Check if you have ever tried the following

MethamphetamineCocaineStimulants (pills)HeroinLSD or HallucinogensMarijuanaPain killers (not as prescribed)MethadoneTranquilizer/sleeping pillsAlcoholEcstasyOther
How many caffeinated beverages do you drink a day?
Tobacco History
Have you ever smoked cigarettes?

YesNo
How many packs per day?
How many years?
Family Background and Childhood History:
Were you adopted?

YesNo
Where did you grow up?
List your siblings and their ages:*
Did your parents divorce?

YesNo
Do you have a history of being abused emotionally, sexually, physically or by neglect? If yes, please describe when, where and by whom.
Personal History
Highest grade completed?
Are you currently:

WorkingStudentUnemployedDisabledRetired
Are you currently:

MarriedPartneredDivorcedSingleWidowed
Do you have any children?

YesNo
Please list ages and gender:*
Have you ever been arrested?

YesNo
Additional information
Emergency Contact

First NameLast Name
Phone Number

Area CodePhone Number
Signature
Guardian Signature (if under age 18)
Should be Empty:

Medical History