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Mental Health Intake Questionnaire - Free Healthcare Template | ZenBuild | ZenBuild

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Mental Health Intake Questionnaire

Collect initial mental health history and current symptoms for new behavioral health patients.

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Mental Health Intake Questionnaire

Collect initial mental health history and current symptoms for new behavioral health patients.

Patient Full Name*

What brings you to seek mental health support?*

How severely are your symptoms impacting daily functioning? (1 = minimal, 5 = severely)*

Have you previously received mental health treatment?*

YesNo

Are you currently taking any psychiatric medications?*

YesNo

Which of the following are you experiencing? (select all that apply)

Sleep disturbancesAppetite changesDifficulty concentratingSocial withdrawalIrritability or mood swings

Is there anything else you would like your provider to know before your first session?

Template Details

CategoryHealthcare

IndustryHealthcare

Fields7

Uses0

Views1

healthcaremental-healthbehavioral-healthintaketherapy