Template: Medical IntakeBehavioral Health Intake Form Form TemplateUse This Template Capture patient information for behavioral health assessment.This is a preview of the template. Click here to use it.Full Name *Date of Birth *Have you ever been diagnosed with a mental health condition? *Are you currently taking any medications for mental health? *Have you experienced any of the following symptoms? *AnxietyDepressionInsomniaMood SwingsSuicidal ThoughtsOtherDo you have any history of substance use? Is there anything else you would like to discuss? Signature *Sign HereUse This Template