Prefer it online? Patients fill it out on their phone before the visit.
Practice name: ______________________________
Mental Health History Form
Your information
Full Name *
Psychiatric Diagnoses History
Current Psychiatric Medications
| Medication | Dose | How often |
|---|---|---|
Past Psychotropic Medications
| Medication | Dose | How often |
|---|---|---|
Therapy History & Modalities
Psychiatric Hospitalizations
Safety Assessment Screen
Substance Use History
Trauma History Screening
Additional details
Current Symptom Severity
Psychosocial Stressors
Support Systems
Functional Impairment Level
Coping Mechanisms
Treatment Goals
Family Psychiatric History
Sleep Pattern Assessment
Patient Signature
Date
Mental Health History Form template from formisoft.com. formisoft.com/intake-templates/mental-health-history