Mental Health Intake Form

Purpose: This form is used by mental health professionals to collect important background and psychological health information from new patients. It helps providers better understand the current concerns, personal and medical history, and other relevant factors to provide quality care.

Personal Information

• Full Name: {fullName}
• Date of Birth: {dateOfBirth}
• Gender: {gender}
• Phone Number: {phoneNumber}
• Email Address: {email}
• Address: {address}

Emergency Contact

• Name: {emergencyContactName}
• Phone: {emergencyContactPhone}
• Relationship: {emergencyContactRelation}

Insurance Information

{#hasInsurance}

• Insurance Provider: {insuranceProvider}
• Policy Number: {policyNumber}
• Group Number: {groupNumber}

{/hasInsurance}

{^hasInsurance}The patient does not have health insurance.{/hasInsurance}

Presenting Concerns

Please describe the main reasons for seeking mental health services:

{presentingConcerns}

Mental Health History

• Have you previously received mental health services? {previousTreatment}
• If yes, when and where? {previousTreatmentDetails}

Diagnosed Mental Health Conditions

{#diagnosedConditions}

• {conditionName}

{/diagnosedConditions}

Medical History

• Current Medications: {currentMedications}
• Past or Current Medical Conditions: {medicalConditions}

Substance Use

• Do you currently use alcohol? {alcoholUse}
• Do you currently use recreational drugs? {drugUse}
• History of substance abuse treatment? {substanceTreatmentHistory}

Social and Family History

• Lives with: {livingSituation}
• Relationship status: {relationshipStatus}
• Occupation: {occupation}

Immediate Family Members

Name	Relation	Age
{#familyMembers}{name}	{relation}	{age}{/familyMembers}

Mental Health Issues in Family

{#familyMentalHealthIssues}

• {relation}: {condition}

{/familyMentalHealthIssues}

Goals for Therapy

{therapyGoals}

Additional Notes

{additionalNotes}