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Mental Health Intake Form Template

Streamline patient onboarding with our mental health intake form

Gathering essential information from new patients can be overwhelming, but it doesn't have to be. This Mental Health Intake Form Template helps therapists and mental health practitioners efficiently collect patient history, consent forms, and insurance details while ensuring data security. With customizable fields, you can accommodate various specialties and facilitate smoother patient interactions, improved data accuracy, and better compliance with HIPAA standards. Get started with this user-friendly template to simplify your intake process today.

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Full name
Date of birth
Email address
Mobile phone number
Gender identity
Woman
Man
Non-binary
Prefer to self-describe
Prefer not to say
Preferred contact methods
Phone call
SMS text
Email
Patient portal message
No preference
Emergency contact full name
Emergency contact phone number
What brings you in today?
What are your top goals for counseling?
Are you comfortable using telehealth (video) sessions?
Yes
No
Have you ever been diagnosed with any of the following?
Please Specify:
Have you seen a mental health professional before?
Yes
No
Current medications (if any)
In the past month, how often did you use alcohol or drugs?
Never
Rarely
Sometimes
Often
Always
Prefer not to say
In the past month, have you had thoughts of harming yourself?
Yes
No
Prefer not to say
Little interest or pleasure in doing things
Very rarely
Rarely
Sometimes
Often
Very often
Feeling down, depressed, or hopeless
Very rarely
Rarely
Sometimes
Often
Very often
Feeling nervous, anxious, or on edge
Very rarely
Rarely
Sometimes
Often
Very often
Not being able to stop or control worrying
Very rarely
Rarely
Sometimes
Often
Very often
I consent to receive mental health services from the provider
Strongly disagree
Disagree
Neither
Agree
Strongly agree
Typed signature (enter your full legal name)
Signature date
I acknowledge that I have reviewed the Notice of Privacy Practices
Strongly disagree
Disagree
Neither
Agree
Strongly agree
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colorful paper art illustration depicting a mental health intake form with pens and calming elements in the background

When to use this form

This form is ideal before a first appointment in private practice, community clinics, school counseling, or telehealth. Use it to screen new clients, triage risk, and capture history when someone is switching providers or seeking support after a recent stressor. You get a clear picture of symptoms, safety, supports, and goals so you can plan care fast and reduce first-session paperwork. For admin details like demographics and insurance, pair it with a Client intake form. If you plan to include parents, partners, or caregivers in treatment, add a Family therapy intake form to gather their perspective.

Must Ask Mental Health Intake Questions

  1. What brings you in today, and what are your top concerns and goals?

    This establishes priorities in the client's own words and sets expectations for care. It helps you focus the first session and choose the right screening or tools.

  2. How long have these issues been present, and how do they affect your daily life at work, school, or home?

    Duration and impact help you gauge severity and impairment. This guides level of care, frequency of sessions, and documentation needs.

  3. What mental health diagnoses, medications, or treatments have you had, and what was helpful or not?

    Past and current treatment details prevent duplication and reveal what to avoid or continue. If other professionals are involved, coordinate using a Social worker intake form.

  4. Do you have any current thoughts of self-harm or harm to others, access to means, or a safety plan?

    Direct safety questions surface urgent risks and inform crisis protocols. Clear answers help you plan monitoring, involve supports, or refer to higher care.

  5. Who and what supports you, and what are your preferences for care, communication, and follow-up?

    Knowing supports and preferences improves engagement and consent-driven coordination. You can tailor outreach (phone, SMS, email) and set goals clients will commit to.

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