Firearm Psychological Evaluation Intake Questionnaire Form
Please complete this intake questionnaire to help prepare for the evaluation.
Applicant Information
Full Name
*
First Name
Middle Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Preferred Contact Method
*
Phone
Email
Text Message
Mail
Evaluation Background
Reason for Evaluation
*
Evaluation Type
*
Initial Evaluation
Follow-up Evaluation
Current Firearm-Related Context
Behavioral and Safety Screening
Current concerns relevant to this evaluation
*
Stress
Sleep difficulties
Mood changes
Anger or irritability
Substance use concerns
Recent major life changes
Other
Have you received any mental health treatment recently?
*
Yes
No
Prefer not to say
Are there any urgent safety concerns you would like the evaluator to know about?
*
Yes
No
If yes, please briefly describe the concern
Submit
Should be Empty: