Mental Health Intake Form
Today's Date
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Month
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Day
Year
Date
Name
*
First Name
Middle Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
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Area Code
Phone Number
Email
example@example.com
Date of Birth
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Month
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Day
Year
Date
Gender
Primary Care Physician
Physician's Phone Number
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Area Code
Phone Number
Current Therapist
Therapist's Phone Number
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Area Code
Phone Number
What is your major complaint?
Start Date
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Month
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Day
Year
Date
Have you previously suffered from this complaint?
Yes
No
Previous therapist(s) seen for this 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 types
Allergies
What medications are you currently using?
Previous diagnosis/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 grow up?
Family member medical conditions?
Family member mental conditions?
Treated with medication?
Which medications?
Early development:
Where did you grow up?
How often did you move and where?
How old were you when you left home?
Have any immediate family members died?
Who?
Have any committed suicide?
Who?
Describe any neglect you suffered, and by whom:
Trauma suffered and by whom:
Abuse suffered and by whom:
Highest education level completed:
Date completed and location:
Have you ever served in the military?
If yes, where?
Dates of service?
Highest rank achieved?
Present Situation:
Work:
Full time
Part time
Student
Unemployed
Disabled
Retired
Are you married?
Date of marriage?
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Month
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Day
Year
Date
Are you divorced?
Date of divorce?
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Month
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Day
Year
Date
Prior marriages?
If yes, how many?
What is your sexual orientation?
Are you sexually active?
How is your relationship with your partner?
Do you have children?
What are their dates of birth?
How is your relationship with your children?
List anyone else who lives with you:
Are you a member of a religion/spiritual group?
What is your level of involvment?
Have you ever been arrested?
When and why?
Have you ever tried the following (check all that apply):
Alcohol
Tobacco
Marijuana
Hallucinogens (LSD)
Heroin
Methamphetamines
Cocaine
Stimulants (Pills)
Ecstacy
Methadone
Tranquilizers
Pain Killers
If yes to any, list frequency/dates of use:
Have you ever been treated for drug/alcohol abuse?
If yes, when?
For which substances?
Do you smoke cigarettes?
If yes, how many per day?
Do you drink caffeinated beverages?
if yes, how many per day?
Have you ever abused prescription drugs?
if yes which ones?
Anything else you want the doctor to know?
Signature
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Date
*
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Month
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Day
Year
Date
Submit
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