Mental Health Therapy Intake Assessment Form

Mental Health Therapy Intake Assessment Form — Form Fields

This healthcare template includes 11 fields. Collect background and presenting concerns from new therapy clients before the first session. Free to customize and use on ZenBuild.

• Client Full Name (text, required)
• Client Email (email, required)
• Date of Birth (text, required)
• Emergency Contact Name and Phone (text, required)
• Referral Source (dropdown selection, required) — options: Self-Referred, Primary Care Physician, Insurance, School, Friend/Family, Other
• Presenting Concerns (checkboxes, required) — options: Anxiety, Depression, Trauma, Grief, Relationship Issues, Work Stress, Substance Use, ADHD, Other
• Describe Your Main Reason for Seeking Therapy (long text, required)
• Have you been in therapy before? (dropdown selection, required) — options: Yes – currently, Yes – in the past, No
• Current Medications (dropdown selection, required) — options: None, Antidepressant, Anti-anxiety, Mood Stabilizer, Other
• Are you currently experiencing thoughts of self-harm or suicide? (multiple choice, required) — options: No, Yes – please contact me immediately
• What are your goals for therapy? (long text, optional)