Mental Health History Form

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.