Mental Health History Form
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Mental Health History Form
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The Mental Health History Form is a thorough psychiatric and behavioral health intake template designed to capture the full scope of a patient's mental health background. It documents prior psychiatric diagnoses (mood disorders, anxiety disorders, psychotic disorders, personality disorders, neurodevelopmental conditions, eating disorders, PTSD), age of onset, treating providers, and current diagnostic status. The medication history section captures all current and past psychotropic medications including antidepressants, anxiolytics, mood stabilizers, antipsychotics, and stimulants -- with dosages, duration, efficacy ratings, and reasons for discontinuation.
The form includes detailed therapy history covering modalities tried (CBT, DBT, EMDR, psychodynamic, family therapy, group therapy), duration of treatment, and perceived benefit. Psychiatric hospitalization and crisis intervention history is documented with dates, facilities, presenting problems, and discharge diagnoses. A safety assessment section screens for current and past suicidal ideation, suicide attempts, self-harm behaviors, and homicidal ideation, using validated screening language that balances clinical thoroughness with patient sensitivity.
Substance use history is integrated with mental health documentation to support dual-diagnosis assessment. Trauma history screening uses a tiered approach -- initial yes/no screening with optional detailed narrative -- respecting patient readiness for disclosure. The form also captures psychosocial stressors, support systems, coping mechanisms, treatment goals, and functional impairment across work, relationships, and daily living domains. It is used by psychiatry practices, psychotherapy clinics, community mental health centers, and integrated behavioral health programs in primary care.
What's included
- Comprehensive psychiatric diagnosis and treatment timeline
- Psychotropic medication history with efficacy ratings
- Therapy modality history and treatment response
- Safety assessment and crisis intervention documentation
- Trauma history screening with tiered disclosure approach
- Functional impairment and psychosocial stressor assessment
- E-signature capture
- Structured medication list with dosage and frequency tracking
Who uses this template
- Psychiatry and psychology practice intake assessment
- Community mental health center initial evaluation
- Integrated behavioral health primary care screening
- Inpatient psychiatric admission documentation
All form fields
18 fields across 3 pages. Customize any field after signing up.
How to use the Mental Health History Form
Getting started with this template takes just a few minutes. Sign up for a free Formisoft trial, then select the Mental Health History Form from the template library. The form is ready to use immediately, but you can customize every field, add your practice logo, and adjust the layout to match your workflow.
Setup steps
- 1Choose the template. Find the Mental Health History Form in the template library and click “Use this template” to add it to your account.
- 2Customize fields. Add, remove, or reorder any of the 18 fields. Set fields as required or optional based on your practice needs.
- 3Brand it. Upload your logo, pick your colors, and add a custom welcome message so patients see your practice identity.
- 4Share with patients. Send the form via SMS, email, or embed it on your website. Patients complete it on any device before their visit.
- 5Review submissions. Responses appear in your dashboard in real time. Patient records are created automatically from the data collected.
Frequently asked questions
Is the Mental Health History Form HIPAA compliant?
Yes. All Formisoft templates, including the Mental Health History Form, are HIPAA compliant. Data is encrypted with 256-bit AES at rest and TLS 1.3 in transit. A Business Associate Agreement (BAA) is included on every plan.
Can I customize the fields in this template?
Absolutely. You can add, remove, reorder, or modify any of the 18 fields. You can also add conditional logic, new pages, file uploads, e-signatures, and payment fields.
How do patients fill out this form?
Patients receive a link via SMS, email, or QR code. They complete the form on their phone, tablet, or computer before their appointment. No app download required.
Can I send this form automatically before appointments?
Yes. Formisoft's workflow automation can send intake forms automatically when an appointment is booked. You can set the timing (e.g., 48 hours before the visit) and include reminders for patients who haven't completed it.
Does this template work on mobile devices?
Yes. The Mental Health History Form is fully responsive and works on any device. Most patients complete intake forms on their phone, so every template is optimized for mobile-first use.
Start with this template
Sign up and start customizing the Mental Health History Form for your practice. Set up in minutes.
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