Mental Health Intake Form
Name
First Name
Last Name
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Date of Birth
-
Month
-
Day
Year
Date
Gender
Please Select
Male
Female
Non-binary
Trans man
Trans female
Prefer not to say
Primary Care Physician
First Name
Last Name
What brings you to counseling at this time?
How did you find me?
Have you seen a mental health professional before?
Current Symptoms
Depressed mood
Racing thoughts
Unable to enjoy activities
Excessive worry
Avoidance
Impulsivity
Isolation from others
Panic/anxiety attacks
Loss of interest
Sleep pattern disturbance
Decreased libido
Increase risky behavior
Increased libido
Hallucinations
Crying spells
Concentration/forgetfulness
Sleeping more than usual
Decrease need for sleep
Change in appetite
Excessive energy
Excessive guilt
Increased irritability
Fatigue
Paranoia/suspiciousness
Other
Have you ever had feelings or thoughts that you didn't want to live?
Yes
No
Do you currently feel that you don't want to live?
Yes
No
How often do you have these thoughts?
Have you ever had thoughts or urges to harm others?
Yes
No
Medical History
Do you have any allergies? (If yes, please list them)
List all current prescription medications and how often you take them
Any current medical problems?
Any past medical problems, nonpsychiatric hospitalization, or surgeries?
Reproductive History:
Psychiatric History:
Outpatient treatment
Yes
No
If yes, Please describe when, by whom, and nature of treatment
Psychiatric Hospitalization
Yes
No
If yes, Please describe when, by whom, and nature of treatment
Family Psychiatric History
Has anyone in your family been diagnosed with or treated for:
Bipolar disorder
Depression
Anxiety
Anger
Suicide
Schizophrenia
Post-traumatic stress
Alcohol abuse
Other
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?
Lifestyle Assessment
Do you exercise regularly?
Yes
No
How much do you exercise in a week?
Check if you have ever tried the following
Methamphetamine
Cocaine
Stimulants (pills)
Heroin
LSD or Hallucinogens
Marijuana
Pain killers (not as prescribed)
Methadone
Tranquilizer/sleeping pills
Alcohol
Ecstasy
Other
How many caffeinated beverages do you drink a day?
Do you smoke cigarettes?
Yes
No
Quit- How long ago?
Family Background and Childhood History:
Were you adopted?
Yes
No
Where did you grow up?
List your siblings and their ages:
Did your parents divorce?
Yes
No
Do you have a history of being abused emotionally, sexually, physically, financially, or by neglect? If yes, please briefly describe.
Personal History
Describe your current living situation. Do you live alone, with family, roommates, etc?
What's your highest level of education?
Are you currently:
Working
Student
Unemployed
Disabled
Retired
What do you do for work or school?
Are you currently:
Married
Partnered
Divorced
Single
Widowed
Are you active duty military or a veteran?
Do you have any children?
Yes
No
Please list ages and gender:
Have you experienced trauma? If so, what's the brief headline version of your experience.
Have you ever been arrested?
Yes
No
Is there anything else you'd like me to know about yourself?
What are your goals for therapy? How will you know when your done with therapy?
Emergency Contact
First Name
Last Name
Phone Number
Date
-
Month
-
Day
Year
Date
Signature
Guardian Signature (if under age 18)
Save
Submit
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