Intake Form for Fortis Mentis Wellness

Intake Form for Fortis Mentis Wellness

Please fill out the following information to help us understand your needs and background.
Personal Information
Full Name

First NameMiddle NameLast Name
Date of Birth

MonthDayYear
Date
Contact Information

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Emergency Contact
Emergency Contact Name

First NameLast Name
Relationship to You
Contact Number
Please enter a valid phone number.Format: (000) 000-0000.
Chief Complaint
What brings you to seek psychiatric care at this time? Please describe your primary concerns or symptoms.
Medical History
Do you have any past or current medical conditions, including psychiatric disorders? Please list all relevant medical history.
Medication History
Are you currently taking any medications, including over-the-counter drugs or supplements?

YesNo
If yes, please list the medication names and dosages
Allergies
Do you have any known allergies, particularly to medications? If so, please specify.
Substance Use
Substances used

AlcoholTobacco/NicotineCannabisPrescription medications not as prescribedOther
Frequency of use
Mental Health History
Have you previously received psychiatric treatment or therapy?

YesNo
If yes, when did it occur and what was the outcome?
Family History
Is there a family history of mental health issues? Please specify any relevant conditions in your family.
Goals for Treatment
What are your goals or expectations for treatment? What would you like to achieve through therapy or medication management?
Please verify that you are human*
By signing, you attest to the truthfulness and accuracy of the above answers.
Should be Empty:

Intake Form for Fortis Mentis Wellness

Personal Information

Emergency Contact

Chief Complaint

Medical History

Medication History

Allergies

Substance Use

Mental Health History

Family History

Goals for Treatment