Mental Health Intake Form
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Complete Mental Health Intake Form with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
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2Mental Health Intake Form
Personal Information
Name:
Date:
Address:
Phone:
Email:
DOB:
Sex:
Primary Physician:
Phone:
Current Therapist:
Phone:
Complaint
What is your major complaint?
Start Date:
Have you previously suffered from this complaint?
Previous therapist(s) seen for complaint:
Previous treatment for complaint:
Aggravating Factors:
Relieving Factors:
Current Symptoms (Check All That Apply)
Anxiety
Appetite Issues
Avoidance
Crying Spells
Depression
Excessive Energy
Fatigue
Guilt
Hallucinations
Impulsivity
Irritability
Libido Changes
Loss of Interest
Panic Attacks
Racing Thoughts
Risky Activity
Sleep Changes
Suspiciousness
Medical History
Exercise Frequency:
Exercise Type(s):
Allergies:
What medications are you currently using?
Previous diagnoses/mental health treatment:
Previously treated by:
Previous medications:
Dates treated:
Previous medical conditions:
Previous surgeries:
Family History
Were you adopted?
If yes, at what age?
How is your relationship with your mother?
How is your relationship with your father?
Siblings and their ages:
Are your parents married?
Did your parents divorce?
If yes, how old were you?
Did your parents remarry?
If yes, how old were you?
Who raised you?
Where did you grown up?
Family member medical conditions:
Family member mental conditions:
Treated with medication?
Medications:
Early Development
Where did you grow up?
How often did you move and where?
How old were you when you left home?
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Parent category: Medical