Psychiatrist Client Intake Form

Information you will need

• Do you want to upload the Clinic's logo? af image
• What’s today's date?
• CLIENT ONLY: What’s your name?
• What's the medical record number?
• What's your phone number?
• What are the reasons for seeking help?
• What have you tried to help with the above problems?
• What's your psychiatric history?
• Is it okay to leave a message?
• Have you taken psychiatric medication?
• Are you looking for psychotherapy?
• What psychiatric medications have you taken?
• Are you looking for medication?
• Are you looking for advice?
• Where and when did you receive psychotherapy?
• Have you had psychotherapy?
• Have you received psychiatric hospitalization?
• Where and when were you hospitalized?
• Does the fear of embarrassment cause you to avoid doing things or speaking to people?
• Do you avoid activities in which you are the center of attention?
• Are being embarrassed or looking stupid your worst fears?
• Does it scare you when you feel shaky?
• Does it scare you when you feel faint?
• Does it scare you when your heart beats rapidly?

…and 83 more fields in the PDF.

Completed by the client.

The form includes 1 signature line, a notary acknowledgment.