Behavioral Health Assessment Form

Behavioral Health Assessment Form — Form Fields

This healthcare template includes 7 fields. Screens patients for common behavioral health concerns including depression, anxiety, and substance use. Supports clinical decision-making for referrals and care planning. Free to customize and use on ZenBuild.

• Patient Name (text, required)
• Date of Birth (text, required)
• Primary concern for today's visit (dropdown selection, required) — options: Depression or low mood, Anxiety or worry, Substance use, Trauma or PTSD, Sleep difficulties, Other
• Over the past 2 weeks, how often have you felt down, hopeless, or depressed? (multiple choice, required) — options: Not at all, Several days, More than half the days, Nearly every day
• Are you currently receiving mental health treatment? (multiple choice, required) — options: Yes, No, Previously, not currently
• How would you rate your overall emotional well-being this past week? (rating, required)
• Is there anything else you would like your provider to know? (long text, optional)