Mental Health Intake Form

Screen new therapy clients for mental health history, current symptoms, and treatment goals.

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Screen new therapy clients for mental health history, current symptoms, and treatment goals.

Full Name*

Date of Birth*

Phone Number*

Emergency Contact Name & Phone*

Have you received therapy or counseling before?*

YesNo

Previous Treatment Details

If yes, describe type of therapy, provider, and approximate dates

Current Symptoms*

Select all that apply

AnxietyDepressionSleep DifficultiesRelationship IssuesGrief / LossTrauma / PTSDSubstance UseAnger ManagementSelf-EsteemOther

What brings you to therapy today?*

Current Medications

Include psychiatric and non-psychiatric medications

Are you currently experiencing thoughts of self-harm or suicide?*

Your safety is our priority — please answer honestly

NoPassive thoughts (no plan)Active thoughts

Goals for Therapy*

What would you like to achieve?

Preferred Session Format*

Client Signature*

I confirm the above information is accurate and consent to treatment

By signing, you agree this constitutes an electronic signature.

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