Mental Health Intake Form

Captures a new patient's full history before their first mental health appointment. It covers current symptoms, self-harm risk, medical and psychiatric background, family history, habits and personal circumstances.

Use this template

In the Claude connectors directory

Name

First Name

Last Name

Date of birth

Gender

Primary care physician

First Name

Last Name

Current therapist or counselor

First Name

Last Name

Therapist's phone number

Current symptoms

Low mood Anxiety or worry Panic attacks Sleep problems Appetite changes Poor concentration Irritability Mood swings

Have you ever had thoughts or feelings of not wanting to live?

Yes No

Do you currently feel that you don't want to live?

Yes No

How often do you have these thoughts?

When did you last have thoughts of dying?

Current weight

Current height

Current medical problems

Past medical problems, non-psychiatric hospitalizations or surgeries

Have you had outpatient treatment?

Yes No

If yes, describe when, with whom and the type of treatment

Have you had a psychiatric hospitalization?

Yes No

If yes, describe when, where and the type of treatment

Other medications?

Has anyone in your family been diagnosed with or treated for:

Has a family member been treated with psychiatric medication? If yes, who, which medication and how well it worked

Do you exercise regularly?

Yes No

How much time do you exercise each day?

Tick anything you have ever tried

How many caffeinated drinks do you have a day?

Have you ever smoked cigarettes?

Yes No

How many packs a day?

For how many years?

Were you adopted?

Yes No

Where did you grow up?

Did your parents divorce?

Yes No

Have you experienced emotional, sexual or physical abuse, or neglect? If yes, describe when, where and by whom.

Highest grade completed

Current work or study situation

Current relationship status

Do you have any children?

Yes No

Have you ever been arrested?

Yes No

Additional information

Emergency contact

First Name

Last Name

Phone number

Date

Signature

Sign here

Guardian signature (if under 18)

Sign here

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