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Mental Health Assessment Form Template

Create Effective Mental Health Assessments with Ease

Assessing mental health can be challenging, especially when you need clear and comprehensive insights. This Mental Health Assessment Form Template is designed for mental health professionals and caregivers looking to evaluate someone's psychological state effectively. By using this template, you can streamline your assessment process, ensure accurate reporting, and enhance patient care, all while saving valuable time and resources. With WCAG-aligned labels for accessibility, you'll be able to create reliable reports that foster understanding and support proactive treatments. Explore the live template to see how it can work for you.

Use this Template (FREE) Live Preview
Full name
Age
Under 18
18-24
25-34
35-44
45-54
55-64
65+
If you prefer to self-describe your gender (optional)
Email (optional)
Phone (optional)
Location (city, state or country) (optional)
Gender identity
Woman
Man
Non-binary
Prefer to self-describe
Prefer not to say
Little interest or pleasure in doing things
Never
Rarely
Sometimes
Often
Always
Feeling down, depressed, or hopeless
Never
Rarely
Sometimes
Often
Always
Feeling nervous, anxious, or on edge
Never
Rarely
Sometimes
Often
Always
Not being able to stop or control worrying
Never
Rarely
Sometimes
Often
Always
Trouble falling or staying asleep, or sleeping too much
Never
Rarely
Sometimes
Often
Always
Feeling tired or having little energy
Never
Rarely
Sometimes
Often
Always
Poor appetite or overeating
Never
Rarely
Sometimes
Often
Always
Trouble concentrating on things
Never
Rarely
Sometimes
Often
Always
Panic or sudden rushes of fear
Never
Rarely
Sometimes
Often
Always
Unwanted memories, nightmares, or flashbacks
Never
Rarely
Sometimes
Often
Always
Periods of unusually high energy, needing less sleep, or feeling overly confident
Never
Rarely
Sometimes
Often
Always
Hearing or seeing things others do not, or strong beliefs others find unusual
Never
Rarely
Sometimes
Often
Always
In the past 2 weeks, have you had thoughts of harming yourself?
Yes
No
Prefer not to say
Do you feel safe where you live?
Yes
No
Prefer not to say
Alcohol use in the past 2 weeks
Never
Rarely
Sometimes
Often
Always
Use of non-prescribed or recreational drugs in the past 2 weeks
Never
Rarely
Sometimes
Often
Always
Using alcohol or drugs to cope with feelings in the past 2 weeks
Never
Rarely
Sometimes
Often
Always
How often have these concerns interfered with your work, school, or daily tasks?
Never
Rarely
Sometimes
Often
Always
Overall, how satisfied are you with your mental wellbeing?
Very dissatisfied
Dissatisfied
Neutral
Satisfied
Very satisfied
How satisfied are you with the support you receive from family or friends?
Very dissatisfied
Dissatisfied
Neutral
Satisfied
Very satisfied
How would you rate your overall quality of life right now?
Poor
Fair
Good
Very good
Excellent
Have you ever been diagnosed with a mental health condition?
Yes
No
Not sure
Prefer not to say
Are you currently receiving mental health care?
Yes
No
On a waitlist
Prefer not to say
Are you currently taking any mental health medication?
Yes
No
Prefer not to say
What types of support are you interested in?
Self-help resources
Therapy or counseling
Medication evaluation
Support group
Crisis support
Not sure
Prefer not to say
How likely are you to seek professional help in the next 30 days?
0 Not at all likely
1
2
3
4
5 Extremely likely
May we contact you about your responses?
Yes
No
Preferred contact methods
Email
Phone call
SMS/Text
Do not contact
Type your full name as your signature confirming the information provided is accurate to the best of your knowledge
Date
Best time to contact you
Morning
Afternoon
Evening
Any time
Do not contact
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paper art illustration featuring a mental health assessment form with various sections and checkboxes

When to use this form

Use this form during intake, routine check-ins, or when a client shows new or worsening symptoms. It helps you capture mood, anxiety, sleep, substance use, and risk in one place, so your team can act quickly. For structured severity ratings, pair it with the Hamilton depression rating scale form or the DASS Form. In primary care, schools, or workplaces, it supports early triage and timely referrals. For broad screening across many domains, add the DSM-5 Level 1 cross-cutting symptom measure assessment form to flag areas that need a deeper review. The outcome: consistent notes, safer decisions, and a baseline you can track over time.

Must Ask Mental Health Assessment Questions

  1. What concerns or symptoms are you experiencing right now?

    This clarifies the presenting problem and sets priorities for the session. Clear focus leads to faster, more relevant follow-ups.

  2. How long have these issues been happening, and what triggers or patterns do you notice?

    Duration and patterns help you distinguish an acute episode from a chronic condition. Triggers guide coping plans and timing of interventions.

  3. How are these symptoms affecting your work, school, relationships, sleep, or self-care?

    Functional impact shows severity and urgency, informing level of care. For ongoing tracking between visits, you can pair responses with the Mental health survey form.

  4. Have you had thoughts of harming yourself or others, or any recent self-harm or attempts?

    Direct risk questions support immediate safety planning and escalation when needed. Clear language reduces ambiguity and encourages honest disclosure.

  5. What medications, substances, or health conditions should we consider?

    This identifies factors that can mimic or worsen psychiatric symptoms and affect treatment choices. It also flags interactions and contraindications before you set a plan.

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