Prefer it online? Patients fill it out on their phone before the visit.
Practice name: ______________________________
Mental Health Intake Form
Your information
Full Name *
Phone Number
Email Address
Reason for Seeking Treatment
How have you been feeling recently?
Tell us about any worries or anxiety
Previous Therapy/Counseling
Additional details
Current Medications (Psychiatric)
| Medication | Dose | How often |
|---|---|---|
Substance Use History
Safety Assessment
Treatment Goals
Emergency Contact
Name
Relationship
Phone
Information acknowledgment
I confirm that the information I have provided is accurate to the best of my knowledge. I can contact the practice to correct or update it.
Signature
Date
Mental Health Intake Form template from formisoft.com. formisoft.com/intake-templates/mental-health-intake