Mental Health Intake Form

Mental Health Intake Form
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth*

MonthDayYear
Date
Gender
Social Security Number*
Primary Care Physician

First NameLast Name
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

	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 Background and Childhood History:
Were you adopted?

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
Additional information
Emergency Contact

First NameLast Name
Phone Number
Date

MonthDayYear
Date
Signature

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Guardian Signature (if under age 18)

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Should be Empty:

Medical History