Mental Health Intake Form

Mental Health Intake Form — Form Fields

This healthcare template includes 13 fields. Screen new therapy clients for mental health history, current symptoms, and treatment goals. Free to customize and use on ZenBuild.

• Full Name (text, required)
• Date of Birth (text, required)
• Phone Number (text, required)
• Emergency Contact Name & Phone (text, required)
• Have you received therapy or counseling before? (multiple choice, required) — options: Yes, No
• Previous Treatment Details (long text, optional) — If yes, describe type of therapy, provider, and approximate dates
• Current Symptoms (checkboxes, required) — options: Anxiety, Depression, Sleep Difficulties, Relationship Issues, Grief / Loss, Trauma / PTSD, Substance Use, Anger Management, Self-Esteem, Other — Select all that apply
• What brings you to therapy today? (long text, required)
• Current Medications (long text, optional) — Include psychiatric and non-psychiatric medications
• Are you currently experiencing thoughts of self-harm or suicide? (multiple choice, required) — options: No, Passive thoughts (no plan), Active thoughts — Your safety is our priority — please answer honestly
• Goals for Therapy (long text, required) — What would you like to achieve?
• Preferred Session Format (dropdown selection, required) — options: In-Person, Video (Telehealth), No Preference
• Client Signature (signature, required) — I confirm the above information is accurate and consent to treatment