Outpatient Mental Health Intake Survey

Outpatient Mental Health Intake Survey — Form Fields

This healthcare template includes 10 fields. Complete a brief intake survey before your first outpatient mental health appointment. Free to customize and use on ZenBuild.

• Patient Full Name (text, required)
• Date of Birth (text, required)
• Email Address (email, required)
• Phone Number (text, required)
• Primary Reason for Seeking Services (dropdown selection, required) — options: Anxiety, Depression, Trauma/PTSD, Relationship issues, Grief and loss, Anger management, Stress, Other
• Have You Previously Received Mental Health Services? (multiple choice, required) — options: Yes, No
• Brief Description of Current Concerns (long text, required)
• How Are These Issues Affecting You? (checkboxes, required) — options: Work or school, Relationships, Sleep, Concentration, Physical health, Daily activities
• How Urgent Is Your Need for Support? (rating, required)
• Anything Else You Would Like Your Provider to Know? (long text, optional)