Mental Health Intake Form

Mental Health Intake Form
Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Gender
Emergency Contact

First NameLast Name
Emergency Contact Phone Number
Please enter a valid phone number.
Do you have a legal guardian?
Primary Care Physician

First NameLast Name
Current Therapist / Counselor

First NameLast Name
Therapist's Phone Number or Email
Insurance type
Insurance ID 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

	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?
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?
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
Have you ever been arrested?

YesNo
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