Prefer it online? Patients fill it out on their phone before the visit.
Practice name: ______________________________
Behavioral Health Intake Form
Behavioral Health Intake Form Please provide the following information for your behavioral health assessment.
Full Name *
Date of Birth *
____ / ____ / ________
Have you ever been diagnosed with a mental health condition? *
Are you currently taking any medications for mental health? *
Have you experienced any of the following symptoms? *
- Anxiety
- Depression
- Insomnia
- Mood Swings
- Suicidal Thoughts
- Other
Do you have any history of substance use?
Is there anything else you would like to discuss?
Signature
Date
Behavioral Health Intake Form template from formisoft.com. formisoft.com/intake-templates/behavioral-health-intake