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Outpatient Mental Health Intake Survey - Free Healthcare Template | ZenBuild | ZenBuild

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Outpatient Mental Health Intake Survey

Complete a brief intake survey before your first outpatient mental health appointment.

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Outpatient Mental Health Intake Survey

Complete a brief intake survey before your first outpatient mental health appointment.

Patient Full Name*

Date of Birth*

Email Address*

Phone Number*

Primary Reason for Seeking Services*

Have You Previously Received Mental Health Services?*

YesNo

Brief Description of Current Concerns*

How Are These Issues Affecting You?*

Work or schoolRelationshipsSleepConcentrationPhysical healthDaily activities

How Urgent Is Your Need for Support?*

Anything Else You Would Like Your Provider to Know?

Template Details

CategoryHealthcare

IndustryHealthcare

Fields10

Uses0

Views2

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