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Cognitive Behavioral Therapy Medical History Form
Medical History

Cognitive Behavioral Therapy Medical History Form

3 pages•17 fields•HIPAA-ready
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Cognitive Behavioral Therapy Medical History Form

Cognitive Behavioral Therapy Medical History Form

Page 1 of 3

Patient Full Name
Jane Martinez
Date of Birth
03/15/1985
Primary Concern
Enter details here...
Previous Therapy Experience
Enter details here...
Current Medications
Mental Health Diagnoses
Diabetes
Hypertension
Asthma
Heart Disease
Symptom Frequency
Select frequency...
Avoidance Behaviors
Enter details here...
Coping Strategies
Enter details here...
Submit
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This specialized medical history form is tailored for cognitive behavioral therapy practices to gather in-depth information about a patient's psychological background, thought patterns, and behavioral health history. It captures detailed information about previous mental health treatment, current symptoms, cognitive distortions, coping mechanisms, and specific behavioral patterns that will inform CBT treatment protocols.

Ideal for licensed clinical psychologists, CBT specialists, behavioral health clinics, and integrated mental health practices, this form includes sections for identifying automatic thoughts, behavioral triggers, avoidance patterns, core beliefs, and treatment goals. The template enables therapists to develop targeted cognitive restructuring interventions and behavioral activation strategies based on comprehensive patient history and presenting concerns.

What's included

  • Detailed presenting problems and symptom history
  • Previous mental health treatment and therapy experiences
  • Current psychiatric medications and compliance
  • Family mental health history
  • Cognitive distortions and automatic thoughts
  • Behavioral avoidance patterns and triggers
  • Current coping mechanisms and strategies
  • Sleep, appetite, and daily functioning patterns
  • Substance use and self-medication history
  • Treatment goals and expectations for CBT
  • Trauma history and adverse experiences
  • Social support system and relationships

Who uses this template

  • Cognitive Behavioral Therapy Practices
  • Clinical Psychology Centers
  • Behavioral Health Clinics
  • Integrated Mental Health Services
  • Licensed Professional Counselors

All form fields

9 fields across 3 pages. Customize any field after signing up.

Patient Full NameText
Date of BirthDate
Primary ConcernLong Text
Previous Therapy ExperienceLong Text
Current MedicationsMedications
Mental Health DiagnosesConditions
Symptom FrequencyDropdown
Avoidance BehaviorsLong Text
Coping StrategiesLong Text
8 min saved per patient98% patient satisfaction3x faster than paper

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Cognitive Behavioral Therapy Medical History FormUse this template