Mental Health Intake Form
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The Mental Health Intake Form is purpose-built for therapists, counselors, psychiatrists, and behavioral health practices. It goes beyond standard demographics to capture the clinical information mental health providers need before a first session: presenting concerns, mood and anxiety screening questions modeled on PHQ-9 and GAD-7, previous treatment history, current psychiatric medications, and substance use screening.
This template includes a dedicated safety assessment section that screens for suicidal ideation, self-harm history, and access to means -- critical information that helps providers prepare for the first encounter. The treatment goals section helps patients articulate what they hope to achieve in therapy, setting the foundation for collaborative treatment planning.
The form is structured with sensitivity in mind. Instructions use warm, non-clinical language. Optional fields allow patients to share at their comfort level. The multi-page format prevents patients from feeling overwhelmed by the depth of information requested. All responses are encrypted and stored with HIPAA-grade security.
What's included
- PHQ-9 and GAD-7 style mood screening
- Substance use and safety assessment
- Medication list with dosage and frequency tracking
- Therapy goals and expectations
- Emergency contact information
- Consent agreement with e-signature
Who uses this template
- Therapists and licensed counselors
- Psychiatry and behavioral health practices
- Community mental health centers
- Employee assistance programs (EAP)
All form fields
13 fields across 3 pages. Customize any field after signing up.
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