Mental Health Intake Questionnaire for New Patients

Mental Health Intake Questionnaire for New Patients — Form Fields

This healthcare template includes 9 fields. New patients complete a comprehensive mental health intake before their first therapy session. Free to customize and use on ZenBuild.

• Full Name (text, required)
• Email Address (email, required)
• Date of Birth (text, required)
• Primary Reason for Seeking Therapy (dropdown selection, required) — options: Anxiety, Depression, Relationship Issues, Grief, Trauma, Stress, Other
• Have you experienced any of the following? (checkboxes, optional) — options: Panic Attacks, Intrusive Thoughts, Sleep Problems, Appetite Changes, Difficulty Concentrating
• Previous Therapy Experience (dropdown selection, required) — options: None, Some in the Past, Currently in Therapy
• Are you currently taking psychiatric medication? (multiple choice, required) — options: Yes, No
• Current Medications (if any) (text, optional)
• What would you like to achieve through therapy? (long text, required)