Mental Health Intake Form
Please complete all information on this form and bring it to the first visit. It may seem long, but most of
the questions require only a check, so it will go quickly. You may need to ask family members about the family
history. Thank you!
Name______________________________________________________________Date___________________
Date of Birth ____________________ Primary Care Physician_______________________________________
Do you give permission for ongoing regular updates to be provided to your primary care physician? _________
Current Therapist/Counselor___________________________ Therapist's Phone_________________________
What are the problem(s) for which you are seeking help?
1.________________________________________________________________________________________
2.________________________________________________________________________________________
3.________________________________________________________________________________________
What are your treatment goals?
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Current Symptoms Checklist: (check once for any symptoms present, twice for major symptoms)
( ) Depressed mood ( ) Racing thoughts ( ) Excessive worry
( ) Unable to enjoy activities ( ) Impulsivity ( ) Anxiety attacks
( ) Sleep pattern disturbance ( ) Increase risky behavior ( ) Avoidance
( ) Loss of interest ( ) Increased libido ( ) Hallucinations
( ) Concentration/forgetfulness ( ) Decrease need for sleep ( ) Suspiciousness
( ) Change in appetite ( ) Excessive energy ( ) ________________
( ) Excessive guilt ( ) Increased irritability ( ) ________________
( ) Fatigue ( ) Crying spells
( ) Decreased libido
Suicide Risk Assessment
Have you ever had feelings or thoughts that you didn't want to live? ( ) Yes ( ) No.
If YES, please answer the following. If NO, please skip to the next section.
Do you currently feel that you don't want to live? ( ) Yes ( ) No
How often do you have these thoughts? ________________________________________________________
When was the last time you had thoughts of dying? ________________________________________________
Has anything happened recently to make you feel this way? _________________________________________
On a scale of 1 to 10, (ten being strongest) how strong is your desire to kill yourself currently? ____________
Would anything make it better? ________________________________________________________________
Have you ever thought about how you would kill yourself? _________________________________________
Is the method you would use readily available? ___________________________________________________
Have you planned a time for this? ______________________________________________________________
Is there anything that would stop you from killing yourself? _________________________________________
Do you feel hopeless and/or worthless? _________________________________________________________
Have you ever tried to kill or harm yourself before? ________________________________________________
Do you have access to guns? If yes, please explain. ________________________________________________