Mental Health Intake Form | PDF Template

Mental health intake forms can differ widely, depending on the circumstances involved. In all cases, mental health issues are complex issues, there are many factors to consider, and many issues to document before treatment can even begin.

How to an Write Intake Form

The first step is always to gather the basic information, such as name, address, phone number and date of birth. If the patient has a primary care physician or is currently being seen by any type of mental health professional, the names and contact information should be noted in the first section of a Mental Health Intake Form.

Next to be noted are the symptoms the patient exhibits. This section of the Mental Health Intake Form will list some common ailments, such as Hallucinations or Panic Attacks. There should be boxes available to check off those that apply.

The Mental Health Intake Form must next note the complaint that caused the patient to seek help. There must be space to state if there has been previous treatment for this issue, and if so, by whom, and when.

There also needs to be a section for information about the patient’s medical history. Medications currently being taken must be noted, as must be any medical conditions. It is also important to enumerate any surgeries the patient has gone through. Exercise type and frequency should be listed, and, of course, previous treatment for mental health issues must be clearly enumerated.

Family History can be very relevant to the course of treatment for a mental health issue, so the mental Health Intake Form will provide spaces to answer the relevant questions. These include the ages of your siblings, if you lived with both your parents and, if your parents divorced, did either or both remarry? There must be a note made of any mental conditions experienced by members of your immediate family. There should also be a few lines to give a very basic idea of your relationship with your parents.

The conditions of your Childhood and your Present Life must also be briefly outlined in the Mental Health Intake form. Did you suffer abuse as a child, and how old were you when you moved out? Have any members of you immediate family attempted or committed suicide? If you were you ever in the military, your service should be briefly outlined. Your educational level and marital status should be described, as should any encounters with the criminal justice system. You sexual orientation is quite relevant, as is your present level of sexual activity.

There should also be a section where you can list or check off any recreational drugs you use, as well as space for describing your use or non-use of alcohol and tobacco.

And finally, because no form can possibly ask every question, there must be some space where you can tell the provider, in your own unencumbered words, any information that is as yet not noted that you think might be relevant.

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