Mental Health Intake Form

Welcome to Thrive Psychotherapy

We are committed to supporting you on your path to well-being. Please take a few moments to complete this intake form, which will help us better understand your needs and ensure we provide care tailored to you. Feel free to share any details that you believe are important. A professional will carefully review your responses to match you with the most suitable therapist. Rest assured, all information provided is confidential and will be used solely to enhance your care experience.
Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Gender
What kind of therapy are you seeking?
Main Area of Concern
Main Mode of Therapy
Current Mental Health Concerns

Other
Have you ever had feelings or thoughts that you didn't want to live?
Do you currently feel that you don't want to live?
How often do you have these thoughts? When was the last time you had thoughts of dying?
Current Therapist / Counselor (if you are seeing someone currently)

First NameLast Name
Psychiatric History:
Have you ever received a Mental Health Diagnosis?
If yes, Please describe when, by whom, and nature of treatment
Have you ever received Psychiatric Hospitalization?
If yes, Please describe when, by for what, and nature of treatment
Medical History
Primary Care Physician (if relevant to your care)

First NameLast Name
List all current prescription medications (Psychiatric or other) and how often you take them
Current medical problems
Past medical problems, nonpsychiatric hospitalization, or surgeries
Family Psychiatric History
Has anyone in your family been diagnosed with or treated for:

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?
Controlled Substances and Tobacco History
Check if you have ever tried the following

Other
Please describe your relationship to these substances and frequency of use?
Have you ever smoked cigarettes? How many packs per day? How many years?
How many caffeinated beverages do you drink a day?
Family Background and Childhood History:
Where did you grow up?
Did your parents divorce?
Were you adopted?
Do you have a history of being abused emotionally, sexually, physically or by neglect? If yes, please describe when, where and by whom.
Exercise Level
Do you exercise regularly?
Personal History
Highest grade completed?
Are you currently:
Are you currently:
Do you have any children?
Have you ever been arrested?
Please provide any additional information that may assist us in matching you with the right therapist or that could be helpful in supporting your current care needs.
Emergency Contact

First NameLast Name
Phone Number
Format: (000) 000-0000.
Date

MonthDayYear
By signing below, you acknowledge that the information provided is accurate to the best of your knowledge. You understand that any information shared will be used to support your care and may be shared with your insurance provider or legal guardian as required by law or for billing purposes. Confidentiality will be maintained in accordance with federal and state laws, including specific protections for minors aged 12 and older in Colorado.
Should be Empty:

Welcome to Thrive Psychotherapy

Psychiatric History:

Medical History

Family Psychiatric History

Controlled Substances and Tobacco History

Family Background and Childhood History:

Exercise Level

Personal History