Start the therapeutic relationship with clinical depth. This mental health intake form collects a client's presenting concerns in their own words, a comprehensive symptom checklist, psychiatric treatment history, current medications, family psychiatric history, treatment goals, and a critical safety screening question — giving your clinician a complete clinical picture before the first appointment begins.
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A mental health intake form is one of the most clinically sensitive documents in behavioral health. Unlike a general medical intake, it asks clients to disclose symptoms that carry stigma — depression, psychosis, trauma, suicidal thoughts — often to a provider they've never met. The form design must balance clinical comprehensiveness with psychological safety: asking everything clinically necessary while maintaining language that feels respectful, human, and non-judgmental.
This template is structured to do exactly that. It opens with a warm, confidentiality-affirming introduction and an open-ended presenting concern field that invites clients to tell their story before checking any boxes. The symptom checklist that follows is comprehensive — it includes psychosis, suicidality, and self-harm alongside the more common depression and anxiety items — because these symptoms are too important to miss and clients are more likely to disclose them when directly asked than when left to volunteer the information. The safety question at the end is phrased to distinguish passive from active ideation and includes a clear pathway for clients in crisis.
formformform is particularly well-suited for mental health practices because the form is delivered as a secure link rather than a paper clipboard in a public waiting room. Clients can complete it privately at home, taking whatever time they need. Responses arrive in your dashboard before the appointment, giving your clinician time to review the safety question and other high-priority items before the session begins. If a client discloses active suicidal ideation, the clinician knows before they walk in the door.
Use your own copy to change labels, remove questions and add the details you need. Try the preview alongside this guide to see what respondents will be asked.
Review the starting questions and choices. You can change them in your own copy.
Jane Doe
you@email.com
(555) 123-4567
Name: Jane Smith | Phone: (555) 987-6543
Share what has been going on and what you are hoping to address in treatment
Include types of treatment (therapy, medication, hospitalization), approximate dates, and what was helpful or unhelpful
Describe what you hope to achieve or change through this treatment
Suggested uses, and why this starting point can help. Adapt the questions to your own process.
Use this as a starting point when you need the same essential information from each person. Review the questions against your process before sharing your copy. Review “Date of Birth” in particular and adapt it to the detail you need.
Use this as a starting point when you need the same essential information from each person. Review the questions against your process before sharing your copy. Review “What brings you in? Please describe your main concerns.” in particular and adapt it to the detail you need.
Use this as a starting point when you need the same essential information from each person. Review the questions against your process before sharing your copy. Review “Which of the following are you currently experiencing?” in particular and adapt it to the detail you need.
Use this as a starting point when you need the same essential information from each person. Review the questions against your process before sharing your copy. Review “Have you received mental health treatment before?” in particular and adapt it to the detail you need.
Designed for high-volume community mental health settings with a broad symptom screen and insurance and income-based payment fields.
Collects medical clearance information, current crisis level, substance use, and treatment motivation for residential program admissions.
Use this as a starting point when you need the same essential information from each person. Review the questions against your process before sharing your copy. Review “Is there a family history of any of the following psychiatric conditions?” in particular and adapt it to the detail you need.
Uses age-appropriate language to collect academic stressors, social functioning, sleep, and substance use for college student clients.
Click "Use this template" to open the mental health intake form in the formformform builder.
Review the symptom checklist and customize it to match your practice's diagnostic focus — an eating disorder specialist would add eating behavior items; an ADHD specialist would add executive function and attention items.
Update the safety question language to align with your practice's clinical protocol and crisis response procedure.
Add a confidentiality and HIPAA disclosure paragraph so clients understand the limits of confidentiality before sharing sensitive information.
Configure email notifications to your clinician's inbox so the pre-visit summary arrives before the appointment start time.
Send the form link with appointment confirmations and ask clients to complete it at least 24 hours before their first session.
the first paragraph sets the emotional tone of the entire intake experience. Thank clients for taking this step; acknowledge that the questions may feel personal; reassure them that their answers are confidential.
research shows clients are more likely to disclose these symptoms when directly asked via a checklist than when asked in an open-ended way. Normalizing the question removes some of the stigma barrier.
'I sometimes wish I wasn't here' is clinically different from 'I have a plan.' The option list in this template makes that distinction explicit.
clients who have had traumatic experiences in prior treatment may not feel safe disclosing details on a form. Make the open-ended history field optional and revisit it in session when trust is established.
the presenting concerns and goals fields give clinicians insight into what the client expects from treatment, which is critical information for setting realistic expectations.
when a client indicates active suicidal ideation, someone must call them before their appointment. A form that asks about safety without a follow-up protocol creates liability.
Collects complete psychiatric history, current symptom picture, and medication details before an initial psychiatric evaluation appointment.
Designed for high-volume community mental health settings with a broad symptom screen and insurance and income-based payment fields.
Focuses on attention, executive function, academic history, and prior ADHD diagnoses or treatments before a comprehensive ADHD evaluation.
Includes trauma type screening, PTSD symptom checklist, current avoidance behaviors, and safety assessment for trauma-specialized practices.
Gathers eating behavior history, medical complications, prior treatment attempts, and body image concerns before an eating disorder evaluation.
Screens substance use history, withdrawal risk, co-occurring psychiatric conditions, and prior detox or rehabilitation episodes.
Collects developmental history, school performance, behavioral concerns, and family psychiatric history for a child's initial psychiatric evaluation.
Uses age-appropriate language to collect academic stressors, social functioning, sleep, and substance use for college student clients.
Screens for postpartum depression, anxiety, OCD, and psychosis with questions specific to pregnancy and the postnatal period.
Assesses cognitive changes, late-life depression, grief, polypharmacy, and social isolation for older adult clients in geriatric psychiatry settings.
Uses occupationally sensitive language to reduce stigma for police, firefighters, and paramedics seeking mental health support.
Includes inclusive gender identity and sexual orientation fields with trauma-informed framing to welcome LGBTQ+ clients from the first touchpoint.
Collects medical clearance information, current crisis level, substance use, and treatment motivation for residential program admissions.
Gathers technology comfort, time zone, scheduling preferences, and crisis support resources available to the client for remote therapy onboarding.
The form does not automatically trigger any crisis response — it collects information. Before deploying this form, establish a clear protocol: ideally a staff member reviews new submissions daily (or on a notification email trigger) and contacts any client who reports active thoughts before their appointment. Include your crisis line and emergency contact information in the form confirmation message.
Yes, though you may want to expand the current medications section. Add fields for dosage, prescribing provider, and duration of use for a more complete medication history for a psychiatric evaluation or med-management visit.
Yes. You can add the PHQ-9 items as a series of radio or number fields, or add a dropdown for each item. Many practices send the clinical assessment tools separately on a timed basis rather than at initial intake.
formformform stores data securely and submissions are only accessible to the account holder. For your HIPAA obligations, consult your compliance officer about your specific data handling workflows — including how you store, access, and delete form submissions.
Yes. Duplicate the template and customize it for outpatient individual therapy, intensive outpatient programs, partial hospitalization, or inpatient pre-admission screening — each requires a different depth of clinical information.
For adolescents (typically 13+), consider having both the teen and a parent complete separate versions. For younger children, a parent-completed version with developmental history and behavior concerns is more appropriate. Create separate templates for each population.
Gather client background and goals before the first therapy session.
Collect patient info, medical history, and insurance before the appointment.
Collect informed consent and appointment details before virtual visits.
Take appointment requests with date, time, service type, and reason.
Collect complete patient medical history before appointments.
Gather client history and communication concerns before a first speech therapy session.
Intake for two or more people in the room — who is attending, each person's goal, and contact boundaries.
Structured intake form to assess client needs and connect them with services.
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