• Blue Ridge Hope Mental Health Intake

    Complete this form as honestly and completely as possible.

  • Please allow 15-20 minutes to complete this intake process. The forms are in-depth but will help us pair you with the counselor/therapist we feel may be the best fit for you.

  • Client Information

  • Date of Birth*
     - -
  • Format: (000) 000-0000.
  • Is it ok to text this number?*
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Preferred contact method*
  • Service Request Type*
  • Format: (000) 000-0000.

  • Insurance Information

  • Upload Files
    Drag and drop files here
    Choose a file
    Cancelof

  • Initial Screening

    The initial FOUR screening questions are designed to assess your immediate needs and guide your care plan. They are entirely safe to answer honestly; this is a standard triage process, not a pathway to hospitalization.
  • Is the client a minor? (under the age of 18)*

  • Presenting Concerns & Symptoms

  • 6. Current symptoms*
  • 10. Desire for treatment*

  • Medical & Health History

  • 12. Medical Conditions*
  • Rows

  • Substance Use & Legal History

  • Prior Mental Health Treatment

  • 26. Do you have (or have you had) any of these concerns (check all that apply):

  • Social History & Functioning

  • Family Medical & Psychiatric History

  • Is there a history of any of the following in the family? Please tick the boxes that apply and specify relationship to patient:*
  • Do you have a family (parent, sibling or child) history of (check all that apply):*

  • Minor Intake Form

    Thank you for taking the time to answer these questions below to help save some time in our first appointment. We will discuss these questions in more detail in session. Please complete this form on behalf of your child or adolescent, or your adolescent may wish to complete the form themselves.
  • Who is completing this form?*

  • Presenting Concerns & Symptoms

  • Rows
  • Rows
  • Rows
  • Rows

  • Medical History

  • Rows
  • Other medical or mental health care workers your child is currently seeing:

  • Family Medical & Psychiatric History

  • Is there a history of any of the following in the family? Please tick the boxes that apply and specify relationship to patient:*
  • Do you have a family (parent, sibling or child) history of (check all that apply):*
  • Browse Files
    Drag and drop files here
    Choose a file
    Cancelof

  • You will now be directed to our Office Policies and Informed Consent forms.

  • Should be Empty: