Mental Health Intake Form
Please answer the following questions thoroughly
Demographics
Client Preferred Name:
First Name
Last Name
Client Legal Name:
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First Name
Last Name
Legal Guardian Name (if under 18 or otherwise applicable):
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date Picker Icon
Preferred Pronouns:
*
Please Select
She/Her
He/Him
They/Them
Other:
What race do you identify as?
How would you describe your ethnicity?
What is your current living situation (select all that apply)?
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Living independently in my residence
With parent(s)
With spouse/partner
With children
With other relative
With foster family
With friends/roommates
Temporary housing
Unhoused/homeless
With pets
Other
Highest level of education completed:
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K-8th Grade
High School
College- 4 years
College- Master's/Doctorate
Other
Are you currently:
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Currently Married
Partnered
Previously Married/Divorced
Single
Widowed
Other
Gender Identity:
Sexual Orientation:
Primary language:
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Occupation:
Employer:
Emergency Contact
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First Name
Last Name
Phone Number
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Client or Legal Guardian
Format: (000) 000-0000.
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History
Reason(s) for seeking counseling services (check all that apply):
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Depression
Anxiety
Difficulties at Work
Sexual Concerns
Legal Concerns
Family Concerns
Eating Concerns
Gender Identity
Pregnancy/Adoption
Grief/Recent Loss
Drug/Alcohol Use
Financial Concerns
Marriage/Relationship Concerns
Divorce
Other
Current symptoms/concerns (select all that apply):
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Fears/Phobias
Increased need for sleep
Decreased need for sleep
Appetite changes/Eating concerns
Hallucinations
Difficulty concentrating/forgetfulness
Fatigue
Crying spells
Racing thoughts
Mood swings
Panic attacks
Hopelessness
Loss of interest/enjoyment
Thoughts of self-harm
Social withdrawal
Irritability
Excessive worry
Feeling on edge
Risky behavior
Trembling or shaking
Nausea or stomach discomfort
Fear of dying
Fear of losing control
Heart racing/palpitations
Intrusive thoughts
Repetitive behaviors
Thoughts of hurting others
Other
What brings you to therapy right now?? What is happening in your life or is different? What stressors do you have? What would you like to work on?
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Please give more details about the issues you named above. When did it start? How often does it happen? How does it affect your life? How have you dealt with it so far?
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Have you ever experienced similar or other mental health symptoms before? What was your experience like? When did it happen? Did you get help?
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Has anyone in your family ever experienced mental health or substance use issues? If so, who was it? Did they seek help? How has this affected you and your family?
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Do you have any current or prior medical issues? If so, what was/is it? Have you seen a doctor or other healthcare professional for it? What treatments did you have? Is there a family history of the disease?
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List all current prescription medications and how often you take them. Write "NA" if no current medications.
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Do you now, or have you ever, used alcohol, tobacco, recreational drugs, or prescription medication other than as prescribed? If so, which ones? How often did/do you use and how long did this occur? Please list each substance separately.
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Who did you live with growing up? List the names and relationships of individuals you grew up with.
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What is your current relationship like with the following family members?
Rows
Poor
Good
Great
Not Applicable or Other
Spouse/Partner
Children/Step-children
Parents
Siblings
Employer/Co-workers
Friends
Do you have any concerns about any of the following?
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Mood
Apetite
Energy
Falling Asleep
Staying Asleep
None of the Above
If you selected any of the above concerns, please describe them in detail. When did they start? How are they affecting your daily life?
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Have you been in therapy before? If so, what did you find helpful? What did you like or dislike about your previous therapy experiences?
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On average, how many hours of uninterrupted sleep do you usually get per night?
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On average, how many caffeinated beverages do you drink a day?
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Do you have any children?
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Yes
No
Have you ever experienced or witnessed any of the following traumatic or upsetting events?
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None
Physical Abuse
Domestic Abuse/Violence
Neglect
Emotional Abuse
Sexual Abuse
Community Violence
What social activities and relationships do you engage in? Who are your most important social supports? Do you belong to any social clubs or organizations? How do you like to spend your leisure time?
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Do you exercise regularly? How do you enjoy being physically active?
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What spiritual practices are important to you? Do you belong to any religious, faith, or spiritual community? How do you celebrate spirituality in your life?
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How would you define your culture? What cultural influences are important to you? How do you celebrate culture in your life? What does your cultural background mean to you?
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What was life like as you were growing up at home? Who did you live with? Did you meet development milestones on time or experience any delays? Were your parents and/or family warm and affectionate? How did your family support and discipline you?
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What do you remember about school growing up? What were your friends like when you were younger? What was school like for you? Were you a good student?
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Have you completed any post-secondary education? If yes, where did you study and what kind of degrees or certifications did you receive?
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What significant educational and work/volunteer experiences have you had? Are you currently employed? If so, where and for how long? What other work and educational experiences have you had (such as a stay-at-home parent or semester abroad)? Are you satisfied with your current employment and education?
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Do you have any current or prior legal issues? Were you ever arrested or charged with a crime or misdemeanor? Do you have any involvement with the civil courts, such as a lawsuit or family law matter? If so, please describe them.
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What are your strengths? What would your loved ones say they like about you? What coping skills have been working for you so far? What is important to know that will help make our time more effective for you?
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What are your current goals for therapy? How will we know if therapy is "working?"
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What else is important to know about you?
Primary Care Provider:
First Name
Last Name
Psychiatric/Mental Health Medication Prescriber:
First Name
Last Name
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PHQ9/GAD7
Over the last 2 weeks, how often have you been bothered by the following problems?
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Rows
Not At All
Several Days
More Than Half the Days
Nearly Every Day
1. Little interest or pleasure in doing things
2. Feeling down, depressed or hopeless
3. Trouble falling or staying asleep, sleeping too much
4. Feeling tired or having little energy
5. Poor appetite or overeating
6. Feeling bad about yourself-or that you are a failure or have let yourself or your family down
7. Trouble concentrating on things, such as reading the newspaper or watching television
8. Moving or speaking so slowly that other people could have noticed. Or the opposite-being so figety or restless that you have been moving around a lot more than usual
9. Thoughts that you would be better off dead, or of hurting yourself
Over the last 2 weeks, how often have you been bothered by the following problems?
*
Rows
Not at all
Several Days
More than half the days
Nearly every day
1. Feeling nervous, anxious, or on edge
2. Not being able to stop or control worrying
3. Worrying too much about different things
4. Trouble relaxing
5. Being so restless that it is hard to sit still
6. Becoming easily annoyed or irritable
7. Feeling afraid as if something awful might happen
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Adverse Childhood Experiences Questionnaire
Consider your experiences prior to your 18th birthday.
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Rows
Yes
No
Service Quality1. Did you live with anyone who was depressed, mentally ill, or suicidal?
Did you live with anyone who was a problem drinker or alcoholic?
Did you live with anyone who used illegal street drugs or who abused prescription medications?
4. Did you live with anyone who served time or was sentenced to serve time in a prison, jail, or other correctional facility?
5. Were your parents separated or divorced?
6. How often did your parents or adults in your home ever slap, hit, kick, punch, or beat each other up?
7. How often did a parent or adult in your home ever hit, beat, kick, or physically hurt you in any way (not including spanking)?
8. How often did a parent or adult in your home ever swear at you, insult you, or put you down?
9. How often did anyone at least 5 years older than you (or an adult), ever touch you sexually?
10. How often did anyone at least 5 years older than you (or an adult), try to make you touch them sexually?
11. How often did anyone at least 5 years older than you or an adult, force you to have sex?
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Columbia Screener
Please answer the following questions.
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Rows
Yes
No
1. Have you wished you were dead or wished you could go to sleep and not wake up?
2. Have you actually had any thoughts of killing yourself?
If you answered YES to question #2, please answer questions 3, 4, 5, and 6. If NO to question #2, go directly to question 6.
Rows
Yes
No
3. Have you been thinking about how you might do this?
4. Have you had these thoughts and had some intention of acting on them?
5. Have you started to work out or worked out the details of how to kill yourself? Do you intent to carry out this plan?
6. Have you ever done anything, started to do anything, or prepared to do anything to end your life?
If you answered YES to question #6, please answer the following question:
Rows
Yes
No
8. Was this within the past three months?
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CAGE Questionnaire
Instructions: For each question, select the best answer. When thinking about drug use, include illegal drug use and the use of prescription drugs other than as prescribed.
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Rows
Yes
No
1. Have you ever felt that you ought to cut down on your drinking or drug use?
2. Have people annoyed you by criticizing your drinking or drug use?
3. Have you ever felt bad or guilty about your drinking or drug use?
4. Have you ever had a drink or used drugs first thing in the morning to steady your nerves or to get rid of a hangover?
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Date
*
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Month
-
Day
Year
Date Picker Icon
Signature
*
Submit
Submit
Should be Empty: