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Mental Health Intake Form

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Mental Health Intake Form

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Psychotherapy Intake Form

We kindly ask your cooperation in answering the questions below as accurately as possible since they will assist your counselor in assessing your needs pre-appointment.

Section 1: Demographics & contact information

Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Cell Phone Number
(000) 000-0000
Please enter a valid phone number.
Home Phone Number
(000) 000-0000
Please enter a valid phone number.
Email
example@example.com
Gender
Please Select▾
Age
ex: 23
Birth Date
MM-DD-YYYY▦
Date
Preferred contact method
PhoneEmailText

Section 2: Emergency contacts & safety

Emergency contact name
Relationship
Emergency contact phone
(000) 000-0000
Please enter a valid phone number.
Would you like to share more about your current wellbeing and safety?
NoYes
If yes, please share what you would like us to know
Are you currently experiencing a crisis or thoughts of harm?
NoYes

Section 3: Safety assessment

In the past two weeks, have you had thoughts of self-harm?
NoA littleOften
Have you ever attempted suicide?
NoYes
Are you currently having thoughts of harming yourself or others?
NoYes
Recent thoughts of suicide or self-harm — please describe

Section 4: Medical & mental health history

Current medical conditions
Past mental health diagnoses
Current medications
Allergies

Section 5: Trauma history

Have you experienced any of the following? (check all that apply)
Physical abuseEmotional abuseSexual abuseNeglectDomestic violenceCommunity violenceSerious accident or injurySudden loss of a loved oneNone of the abovePrefer not to say
Approximate age(s) when this occurred
Have you ever received support or therapy related to these experiences?
YesNo
How do these experiences affect you today?

Section 6: Family & social history

Family mental health history
Relationship / marital status
Living situation
Social support
Were you adopted?
YesNo
Where did you grow up?
List your siblings and their ages
Did your parents divorce?
YesNo

Section 7: Current concerns

What brings you in today?
How long has this been present?

Section 8: Goals for therapy

What are your goals for therapy?
What would a successful outcome look like for you?
Which goal feels most important to start with?

Section 9: Substance use history

Substance use history
Frequency of use
Do you exercise regularly?
YesNo
How much time each day do you exercise?
Have you ever tried any of the following? (check all that apply)
MethamphetamineCocaineStimulants (pills)HeroinLSD or hallucinogensMarijuanaPain killers (not as prescribed)MethadoneTranquilizers / sleeping pillsAlcoholEcstasyOther
Have you ever smoked cigarettes?
YesNo
If yes, how many packs per day?
For how many years?
Other behavioral health information

Section 10: Treatment history & medications

Previous treatment or therapy
Current providers
Current medications
Notes

Section 11: Past psychiatric medications

If you have ever taken any of the following medications, please indicate the dates and daily dosage.

Psychiatric medications you have ever taken
Have you ever taken it?DatesDosageSide Effects?
Prozac (fluoxetine)
Zoloft (sertraline)
Luvox (fluvoxamine)
Paxil (paroxetine)
Celexa (citalopram)
Lexapro (escitalopram)
Effexor (venlafaxine)
Cymbalta (duloxetine)
Wellbutrin (bupropion)
Remeron (mirtazapine)
Serzone (nefazodone)
Anafranil (clomipramine)
Pamelor (nortriptyline)
Tofranil (imipramine)
Elavil (amitriptyline)
Tegretol (carbamazepine)
Lithium
Depakote (valproate)
Lamictal (lamotrigine)
Topamax (topiramate)
Seroquel (quetiapine)
Zyprexa (olanzapine)
Geodon (ziprasidone)
Abilify (aripiprazole)
Clozaril (clozapine)
Haldol (haloperidol)
Prolixin (fluphenazine)
Risperdal (risperidone)
Ambien (zolpidem)
Sonata (zaleplon)
Rozerem (ramelteon)
Restoril (temazepam)
Desyrel (trazodone)
Adderall (amphetamine)
Concerta (methylphenidate)
Ritalin (methylphenidate)
Strattera (atomoxetine)
Xanax (alprazolam)
Ativan (lorazepam)
Klonopin (clonazepam)
Valium (diazepam)
Tranxene (clorazepate)
Buspar (buspirone)
Other medications?

Section 12: Primary care physician

Primary care physician name
Clinic or practice name
Phone Number
(000) 000-0000
Please enter a valid phone number.
May we contact your primary care physician about your care?
YesNo

Section 13: Relationship

What is your relationship status?
MarriedSeparatedWidowedOtherNever MarriedDomestic Partnership
How would you rate your relationship well-being?
12345678910
Not functioningNo problems

Section 14: Employment

What is your employment status?
EmployedRetiredDisabledHomemakerOtherUnemployedSelf-employedStudent
Your average monthly income (USD)
ex: 23
USD

Section 15: Family & household

Including yourself, how many people live in your household?
−1+
Total household monthly income (USD)
ex: 23
USD
Family history of any of the following conditions (check all that apply)
YesNoIndicate Family Member
Anxiety
Depression
Substance abuse / alcohol
Arrests
Obesity
Schizophrenia
Suicide attempt
Domestic violence
Additional comments
How would you rate your family relationship?
12345678910
Not functioningNo problems

Section 16: History

Have you previously received any type of mental health services?
YesNo
If yes, please describe the services you received
Are you currently on psychiatric medication?
YesNo

Section 17: General health information

How would you rate your physical health condition?
12345678910
Very PoorExcellent
How often do you exercise?
12345678910
NoneVery Often
How would you describe your general appetite?
12345678910
Very PoorVery Hungry
How would you describe your stress level throughout the day?
12345678910
Very RelaxedVery Stressed
How would you rate your general happiness and well-being?
12345678910
Very unhappyVery happy

Section 18: Symptoms

Please answer all of the statements below that describe your concerns

I often experience
Fear of many thingsGuiltPanic attacksAvoiding peopleHaving nightmaresAnxiety, nervousnessDiscomfort in social situationsSexual issuesOther
I often have
Suicidal thoughtsMemory problemsSleeping disorderStruggled to explain myself to othersObsessive thoughtsViolent thoughtsStress and tensionMedical concernsFatigueWork problemsOther
I often feel
LonelyEmptySadHopeless about the futureExcessive guiltSuspiciousOther

Section 19: Referral source

How did you hear about us?
Doctor or provider referralFriend or familyInsurance directoryOnline searchSocial mediaOther
Referred by (name, if applicable)
Reason for referral (if applicable)

Section 20: Appointment & availability

Please check your available times for a weekly appointment? (Check as many as applies)
MondayTuesdayWednesdayThursdayFriday
9:00 AM - 10:00 AM
10:00 AM - 11:00 AM
11:00 AM - 12:00 PM
1:00 PM - 2:00 PM
2:00 PM - 3:00 PM
3:00 PM - 4:00 PM
4:00 PM - 5:00 PM
Please book an available time for your first appointment?
06/29/2026▦
9:00 AM - 10:00 AM10:00 AM - 11:00 AM11:00 AM - 12:00 PM1:00 PM - 2:00 PM2:00 PM - 3:00 PM3:00 PM - 4:00 PM4:00 PM - 5:00 PM

Section 21: Insurance status

Do you have insurance?
YesNo

Section 22: Consent, notices & policies

I acknowledge the consent, notices, and office policies provided.
I acknowledge
Signature
Your signature
✕
Printed name
Date signed
MM-DD-YYYY▦
Guardian signature (if under age 18)
Your signature
✕
Guardian printed name
Relationship to patient (if applicable)
Submit

Intake forms for mental health care carry more weight than most paperwork: they screen for risk, capture medication and treatment history, and establish consent - all before the first appointment. The structure below reflects what behavioral health practices actually collect.

Use the builder above to assemble yours in minutes: pick a starting template, keep the sections you need, add your own questions, and download a print-ready PDF or send it digitally for e-signature.

What mental health intake forms must capture

  • Identifying information — legal name, date of birth, contact, and emergency contact
  • Presenting problem — symptoms, duration, and what prompted seeking help now
  • Psychiatric history — prior diagnoses, treatment, therapy, and hospitalizations
  • Medication history — current and past psychiatric medications, doses, and responses
  • Medical history — conditions and allergies that shape treatment decisions
  • Substance use — screening questions with follow-ups only when answers call for them
  • Safety screen — recent thoughts of self-harm, with crisis resources shown alongside
  • Family mental health history — patterns that inform assessment
  • Functioning — sleep, appetite, work or school, relationships
  • Consent and policies — treatment agreement, fees, and signature with date

Why digital intake wins for mental health practices

  • Sensitive questions get honest answers — clients disclose more accurately typing at home than writing on a clipboard
  • The safety screen is never skipped — required fields mean the risk questions are always answered
  • Medication tables stay legible — structured rows instead of squeezed handwriting
  • Conditional depth — the psychiatric medication table appears only for clients who take medication
  • The record files itself — every intake arrives as the same organized, signed PDF

Adapting the template to your setting

A solo therapist, a group practice, and a psychiatric NP need different depth from the same skeleton. Keep the sections that fit your scope, add your own screening questions, and set required fields to match your standard of care. The builder above starts from a comprehensive mental health template - trimming takes minutes.

Frequently asked questions

›What should intake forms for mental health include?

Identifying details, presenting problem, psychiatric and medication history, medical background, substance use screening, a safety screen with crisis resources, family mental health history, daily functioning, and signed consent to your policies.

›Do the forms include a medication history table?

Yes - a structured table of psychiatric medications with a "have you ever taken it" column, shown only to clients who indicate they take or have taken medication.

›How is the safety screen handled?

The wellbeing section asks about recent thoughts of self-harm as required questions and displays crisis resources (988, 911) directly alongside, so no client sees the question without the resources.

›Can clients complete the intake before their appointment?

Yes. Send the link by email or text; the completed, signed intake arrives as a PDF before the visit.

›Can I customize the sections for my practice?

Fully - add, remove, rename, and reorder sections, write your own questions, and brand the form with your practice name and logo.

›Does it support clients under 18?

Yes. When a date of birth shows the client is a minor, the form automatically collects a parent or guardian consent and signature.

›What is the cost?

Free to build and preview. $14.99 one-time for a print-ready PDF or a single digital send; plans from $19 per month for unlimited clients.