# Mental Health New Patient Intake Form

| Form ID | FRM-MHO-001 | Revision | 1.0 |
|---------|-------------|----------|-----|

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## Patient Information

| Field | Entry |
|-------|-------|
| Last Name | |
| First Name | |
| Preferred Name | |
| Date of Birth | |
| Age | |
| Sex | ☐ Male ☐ Female ☐ Other |
| Gender Identity | |
| Pronouns | |

### Contact Information

| Field | Entry |
|-------|-------|
| Address | |
| City, State, ZIP | |
| Home Phone | |
| Cell Phone | |
| Email | |
| Preferred Contact Method | ☐ Home ☐ Cell ☐ Email |
| OK to Leave Detailed Message? | ☐ Yes ☐ No |

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## Emergency Contact

| Field | Entry |
|-------|-------|
| Name | |
| Relationship | |
| Phone | |
| Address | |

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## Referral Information

| Field | Entry |
|-------|-------|
| Referred By | |
| Referring Provider Phone | |
| Primary Care Physician | |
| PCP Phone/Fax | |
| Current Therapist (if any) | |
| Current Prescriber (if any) | |

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## Reason for Seeking Treatment

**What brings you in for treatment today?**

**What are your main symptoms or concerns?**

**When did these symptoms start?**

**What do you hope to get out of treatment?**

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## Symptom Checklist

*Check all symptoms you are currently experiencing:*

### Mood Symptoms
☐ Depressed mood
☐ Loss of interest/pleasure
☐ Hopelessness
☐ Guilt
☐ Irritability
☐ Mood swings
☐ Elevated/euphoric mood
☐ Decreased need for sleep
☐ Racing thoughts
☐ Increased energy

### Anxiety Symptoms
☐ Excessive worry
☐ Restlessness
☐ Difficulty concentrating
☐ Muscle tension
☐ Sleep problems
☐ Panic attacks
☐ Fear of social situations
☐ Specific phobias
☐ Obsessive thoughts
☐ Compulsive behaviors

### Trauma Symptoms
☐ Flashbacks/intrusive memories
☐ Nightmares
☐ Avoiding reminders of trauma
☐ Emotional numbness
☐ Hypervigilance
☐ Easily startled

### Psychotic Symptoms
☐ Hearing voices
☐ Seeing things others don't see
☐ Paranoid thoughts
☐ Unusual beliefs
☐ Confused thinking

### Other Symptoms
☐ Difficulty concentrating
☐ Memory problems
☐ Impulsivity
☐ Anger problems
☐ Relationship difficulties
☐ Work/school problems
☐ Appetite changes
☐ Weight changes
☐ Fatigue/low energy
☐ Chronic pain

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## Suicidal/Self-Harm History

| Question | Response |
|----------|----------|
| Are you currently having thoughts of suicide? | ☐ Yes ☐ No |
| Are you currently having thoughts of harming yourself? | ☐ Yes ☐ No |
| Have you ever attempted suicide? | ☐ Yes ☐ No |
| If yes, when and how? | |
| Have you ever engaged in self-harm (cutting, burning, etc.)? | ☐ Yes ☐ No |
| If yes, describe: | |

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## Psychiatric History

### Previous Treatment

| Treatment Type | Yes/No | Where | When | Helpful? |
|----------------|--------|-------|------|----------|
| Outpatient therapy | ☐ | | | ☐ Yes ☐ No |
| Outpatient psychiatry | ☐ | | | ☐ Yes ☐ No |
| Intensive outpatient (IOP) | ☐ | | | ☐ Yes ☐ No |
| Partial hospitalization (PHP) | ☐ | | | ☐ Yes ☐ No |
| Psychiatric hospitalization | ☐ | | | ☐ Yes ☐ No |
| Residential treatment | ☐ | | | ☐ Yes ☐ No |
| ECT | ☐ | | | ☐ Yes ☐ No |
| TMS | ☐ | | | ☐ Yes ☐ No |

### Previous Diagnoses

*Check all that you have been diagnosed with:*

☐ Depression
☐ Bipolar Disorder
☐ Anxiety Disorder
☐ Panic Disorder
☐ PTSD
☐ OCD
☐ ADHD
☐ Schizophrenia/Schizoaffective
☐ Personality Disorder (type: _______)
☐ Eating Disorder
☐ Substance Use Disorder
☐ Autism Spectrum Disorder
☐ Other: _______________

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## Current Medications

| Medication | Dose | Frequency | Prescriber |
|------------|------|-----------|------------|
| | | | |
| | | | |
| | | | |
| | | | |
| | | | |

### Past Psychiatric Medications

*List medications you have tried in the past:*

| Medication | Helpful? | Side Effects? | Reason Stopped |
|------------|----------|---------------|----------------|
| | ☐ Yes ☐ No | | |
| | ☐ Yes ☐ No | | |
| | ☐ Yes ☐ No | | |
| | ☐ Yes ☐ No | | |

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## Allergies

☐ No Known Allergies

| Medication/Substance | Reaction |
|---------------------|----------|
| | |
| | |

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## Substance Use History

| Substance | Ever Used | Age First Used | Current Use | Amount/Frequency | Last Used |
|-----------|-----------|----------------|-------------|------------------|-----------|
| Alcohol | ☐ | | ☐ | | |
| Marijuana/Cannabis | ☐ | | ☐ | | |
| Cocaine/Crack | ☐ | | ☐ | | |
| Heroin/Opioids | ☐ | | ☐ | | |
| Methamphetamine | ☐ | | ☐ | | |
| Benzodiazepines (non-Rx) | ☐ | | ☐ | | |
| Tobacco/Nicotine | ☐ | | ☐ | | |
| Other: | ☐ | | ☐ | | |

**Have you ever had treatment for substance use?** ☐ Yes ☐ No

If yes, describe:

---

## Medical History

### Current Medical Conditions

☐ None

| Condition | Notes |
|-----------|-------|
| | |
| | |
| | |

### Past Surgeries/Hospitalizations

| Surgery/Hospitalization | Year |
|------------------------|------|
| | |
| | |

### For Women

| Field | Entry |
|-------|-------|
| Are you pregnant? | ☐ Yes ☐ No ☐ Maybe |
| Are you breastfeeding? | ☐ Yes ☐ No |
| Last menstrual period | |
| Using contraception? | ☐ Yes ☐ No |

---

## Family Psychiatric History

*Check all that apply to biological relatives:*

| Condition | Mother | Father | Sibling | Grandparent | Other |
|-----------|--------|--------|---------|-------------|-------|
| Depression | ☐ | ☐ | ☐ | ☐ | ☐ |
| Bipolar Disorder | ☐ | ☐ | ☐ | ☐ | ☐ |
| Anxiety | ☐ | ☐ | ☐ | ☐ | ☐ |
| Schizophrenia | ☐ | ☐ | ☐ | ☐ | ☐ |
| Substance Abuse | ☐ | ☐ | ☐ | ☐ | ☐ |
| Suicide/Attempt | ☐ | ☐ | ☐ | ☐ | ☐ |
| ADHD | ☐ | ☐ | ☐ | ☐ | ☐ |
| Other: | ☐ | ☐ | ☐ | ☐ | ☐ |

---

## Social History

### Living Situation

| Field | Entry |
|-------|-------|
| Who do you live with? | |
| Type of housing | ☐ Own ☐ Rent ☐ With family ☐ Homeless ☐ Other |
| Housing stability | ☐ Stable ☐ At risk ☐ Unstable |

### Relationships

| Field | Entry |
|-------|-------|
| Marital/Relationship status | ☐ Single ☐ Married ☐ Partnered ☐ Divorced ☐ Widowed |
| Children (ages) | |
| Quality of relationships | ☐ Good ☐ Fair ☐ Poor |
| Social support | ☐ Strong ☐ Some ☐ Limited ☐ None |

### Education/Employment

| Field | Entry |
|-------|-------|
| Highest education | |
| Current employment | ☐ Full-time ☐ Part-time ☐ Unemployed ☐ Disabled ☐ Retired ☐ Student |
| Occupation | |
| Work/school problems? | ☐ Yes ☐ No |

### Legal

| Field | Entry |
|-------|-------|
| Current legal issues? | ☐ Yes ☐ No |
| If yes, describe: | |
| History of incarceration? | ☐ Yes ☐ No |

### Trauma History

*Have you experienced any of the following?*

☐ Physical abuse
☐ Sexual abuse
☐ Emotional/verbal abuse
☐ Neglect
☐ Domestic violence
☐ Witnessed violence
☐ Military combat
☐ Serious accident
☐ Natural disaster
☐ Other trauma: _______________

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## Current Stressors

*Rate your current stress level (1-10):* _____

*What are your main stressors right now?*

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## Strengths and Supports

*What are your strengths?*

*Who are your supports (family, friends, community)?*

*What coping strategies do you currently use?*

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## Goals for Treatment

*What would you like to accomplish through treatment?*

1.
2.
3.

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## Signature

| Field | Entry |
|-------|-------|
| Patient Signature | |
| Date | |
| Guardian Signature (if minor) | |
| Relationship to Patient | |

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## For Office Use

| Field | Entry |
|-------|-------|
| Date Received | |
| Entered By | |
| Appointment Date | |
| Assigned Provider | |
| Notes | |

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*Form FRM-MHO-001 Rev 1.0 - Mental Health New Patient Intake Form*