Mental health intake
A careful, unhurried intake for mental health services, written with empathetic language.
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About you
We'd like to get to know you
Take all the time you need. There are no right or wrong answers — we just want to understand how to support you best. Everything you share is confidential.
Nombre
Apellido
The name you're comfortable with.
How you've been feeling
Check anything that applies — you can always change your mind later.
Very difficultQuite good
This is just a starting point for the conversation, not a diagnosis.
In your own words; a few lines are plenty.
Important: this form is not monitored in real time. If you're in crisis or thinking about harming yourself, please call your local helpline or go to the nearest emergency room — you deserve immediate support.