Mental Health Client Intake Form

Information you will need

• Do you want to upload the Clinic's logo? af image
• CLINIC ONLY: What’s your name or the name of your clinic?
• CLIENT ONLY: What’s your name?
• Who's your primary care physician?
• Who's your current therapist or counselor?
• What’s your current therapist or counselor's phone number?
• Who's your emergency contact?
• What's the emergency contact's phone number?
• What problems are you seeking help for?
• How often do you have these thoughts?
• When was the last time you had thoughts of dying?
• On a scale of 1 to 10, how strongly do you feel these thoughts?
• Have you ever had feelings or thoughts that you didn't want to live?
• Do you currently feel that you don't want to live?
• Do you feel hopeless or worthless?
• Have you tried to kill or harm yourself before?
• Is there anything that would stop you from killing yourself?
• What’s your current weight?
• What’s your current height?
• What's the prescription medication's name?
• What’s the total daily dosage?
• What’s the date you started taking the medication?
• What’s your birth control method?
• How many live births?

…and 256 more fields in the PDF.

Completed by the client.

The form includes 1 signature line, a notary acknowledgment.