Psychiatric Intake Form
Name
First Name
Last Name
Age
Phone Number
Format: (000) 000-0000.
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date of Birth
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Gender
Male
Female
Occupation
Company Name
Emergency Contact Person
First Name
Last Name
Relationship to the patient
Please Select
Father
Mother
Brother
Sister
Relatives
Guardian
Friend
Primary Phone Number of Emergency Contact Person
Please enter a valid phone number.
Format: (000) 000-0000.
Secondary Phone Number of Emergency Contact Person
Please enter a valid phone number.
Format: (000) 000-0000.
Mental Health Status/History
Weight
Height
What issues or problems are you currently experiencing?
Have you received any counseling or psychiatric sessions before?
Yes
No
If yes, please tell us the reason and when.
Please select the following symptoms you are experiencing
Rows
Mild
Moderate
Severe
Aggression
1
2
3
Agitation
4
5
6
Anger
7
8
9
Anxiety
10
11
12
Appetite change
13
14
15
Change in libido
16
17
18
Compulsions
19
20
21
Crying/tearful
22
23
24
Cyber addiction
25
26
27
Delusions
28
29
30
Depression
31
32
33
Disorientation
34
35
36
Difficulty getting out of bed
37
38
39
Difficulty making decisions
40
41
42
Distractibility
43
44
45
Eating disorder
46
47
48
Judgment errors
49
50
51
Loneliness
52
53
54
Loss of interest in activities
55
56
57
Physical trauma perpetrator
58
59
60
Family Psychiatric History (Do you have a family member who was diagnosed with any of these mental conditions?)
Bipolar disorder
Depression
Anxiety
Anger
Suicide
Schizophrenia
Post-traumatic stress
Alcohol abuse
Other substance abuse
Violence
Other
Are you currently taking any psychiatric medications?
Yes
No
If yes, please tell us the medication name, purpose, and the frequency.
Do you have any allergies?
Yes
No
If yes, please tell us more about it.
If you're experiencing any non-psychiatric medical conditions, please list them below so that we are aware of it.
Are you smoking?
Yes
No
If you have history of drinking alcohol, please explain below how often do you do it?
If you have history of taking illegal substance, kindly elaborate below.
Do you have any suicidal thoughts?
Yes
No
Patient's Signature
*
Date Signed
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Therapist Information
Therapist Name
First Name
Last Name
Therapist Phone Number
Format: (000) 000-0000.
Therapist Email Address
example@example.com
Therapist Signature
Date Signed
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
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Print Form
Submit
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