Mental Health Intake Questionnaire

Mental Health Intake Questionnaire — Form Fields

This healthcare template includes 7 fields. Collect initial mental health history and current symptoms for new behavioral health patients. Free to customize and use on ZenBuild.

• Patient Full Name (text, required)
• What brings you to seek mental health support? (dropdown selection, required) — options: Anxiety or worry, Depression or low mood, Trauma or PTSD, Relationship difficulties, Grief or loss, Other
• How severely are your symptoms impacting daily functioning? (1 = minimal, 5 = severely) (rating, required)
• Have you previously received mental health treatment? (multiple choice, required) — options: Yes, No
• Are you currently taking any psychiatric medications? (multiple choice, required) — options: Yes, No
• Which of the following are you experiencing? (select all that apply) (checkboxes, optional) — options: Sleep disturbances, Appetite changes, Difficulty concentrating, Social withdrawal, Irritability or mood swings
• Is there anything else you would like your provider to know before your first session? (long text, optional)