Digital Mental Health Intake Form / Client Forms

Digital Mental Health
Intake Form

Section 1:
DEMOGRAPHICS & CONTACT INFORMATION

Full Legal Name: *

Date *

Preferred Name:

Pronouns *

He/Him
She/Her
They/Them
Other

Date of Birth: *

Age: *

Racial/Ethnic Identity *

Hispanic or Latino
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White

Gender Identity: *

Man
Woman
Non-Binary
Genderqueer
Agender
Two-Spirit
Prefer Not to Say

CURRENT ADDRESS

Street Address: *

City: *

State *

Zip Code *

Phone Number *

Email Address: *

EMERGENCY CONTACT

Name: *

Relationship: *

Emergency Contact Phone Number: *

Section 2:
REASON FOR SEEKING THERAPY

What brings you to therapy at this time? *

When did you first start noticing these concerns? *

How long have these issues been present? *

Have you sought mental health support in the past? *

Yes
No

If yes, when was this?

What type of support did you receive? (e.g. individual therapy, group therapy, medication management etc)

What was helpful/unhelpful about that experience(s)?

What are your primary goals for therapy? What do you hope to achieve? *

What is your understanding of how therapy works? *

Section 3:
CURRENT SYMPTOMS & CHALLENGES

Check all that apply. *

Anxiety/Nervousness
Depressed Mood
Irritability/Anger
Changes in Appetite/Weight
Difficulty Concentrating
Feeling Worthless/Guilty
Suicidal Thoughts
Intrusive Thoughts/Obsessions
Flashbacks/Nightmares
Social Withdrawal
Grief/Loss
Substance Use Concerns
Body Image Issues
Trauma History
Panic Attacks
Lost of Interest/Pleasure
Sleep Difficulties (Insomnia, Hypersomnia)
Fatigue/Low Energy
Stress Management Issues
Eating Concerns
Chronic Pain
Other

On a scale of 1-10, how much distress do these symptoms cause you? *

How do these symptoms impact your daily life? (e.g. work, relationships, self-care, etc) *

Section 4:
SAFTEY INFORMATION
(Crucial - Requires immediate clinician review if concerns arise.)

Are you currently experiencing thoughts of harming yourself? *

Yes
No

If yes, do you have a plan?

Do you have access to means?

Yes
No

If yes, what is your access to?

How often to do you have these thoughts?

Are there things that prevent you from acting on these thoughts?

Have you attempted suicide in the past? *

Yes
No

If yes, when and what was the method?

Are you currently experiencing thoughts of harming others? *

Yes
No

If yes, please elaborate.

Have you acted on these thoughts in the past? *

If yes, please explain.

Section 5:
MENTAL HEALTH HISTORY

Have you ever been diagnosed with a mental health condition? *

Yes
No

If yes, please list diagnosis/diagnoses and approximate date of diagnosis.

Are you currently taking any psychiatric medications? *

Yes
No

If yes, please list medications(s), dosage and prescribing doctor.

Have you ever been hospitalized for a mental health concern? *

Yes
No

If yes, When, where, and for what reason?

Have you ever had a history of substance abuse or addiction? *

Yes
No

(Alcohol, illicit drugs, prescription medications etc.)

If yes, please describe.

Do you have a family history of mental health conditions? *

Yes
No

If yes, please specify relationship and condition. (mother - depression, Brother - anxiety)

Section 6 :
MEDICAL HISTORY & HEALTH

Are you currently under the care of a medical doctor? *

Yes
No

If yes, please provide their name and specialty.

Do you have any significant medical conditions? *

Yes
No

If yes, please list.

Are you taking any non-psychiatric medications, supplements, or herbal remedies? *

Yes
No

If yes, please list.

When was your last physical examination? *

Do you have any current or past history of head injuries or concussions? *

Yes
No

If yes, please describe.

Do you have any current or past history of neurological conditions? *

Yes
No

If yes: please describe.

Please describe your typical sleep patterns. (e.g.hours of sleep, difficulty falling/staying asleep. *

Please describe your typical appetite and eating habits. *

Section 7:
SOCIAL & FAMILY HISTORY

Marital/Relationship Status: *

Married
Divorced
Single

Do you live alone or with others? *

Describe your current living situation. *

Do you feel you have adequate social support? *

Yes
No

Please explain. *

Are you currently employed? *

Yes
No

If yes: Occupation/Industry:

If no: Reason for unemployment

Highest level of education completed: *

Please describe your relationship with your family of origin. (Parents, Siblings, Close Relatives) *

Do you have any significant family stressors or concerns? Please explain. *

Have you experienced any significant losses or bereavements recently? *

Yes
No

If yes, please describe.

Section 8:
STRENGTHS & COPING MECHANISIMS

What are your personal strengths, resources, and qualities? *

What ares some ways you currently cope with stress or difficult emotions? *

What are your hobbies, interests, or activities that bring you joy? *

Do you have any spiritual or religious beliefs that are important to you? *

Yes
No

If yes, please describe their role in your life.

Section 9:
EXPECTATIONS & CONSENT

What are your expectations of therapy? *

Is there anything else you would like your therapist to know before your first session?

Section 10:
LEGAL & ADMINISTRATIVE

Informed Consent for Treatment: *

I have read and understand the informed consent for therapy services, including information on confidentiality, its limits, fees, cancellation policy, and emergency procedures. I agree to these terms.

Notice of Privacy Practices (HIPAA/GDPR equivalent): *

I have received and reviewed the Notice of Privacy Practices.

Consent to Bill Insurance/Self-Pay Agreement: *

I understand the fee structure and agree to be responsible for payment for services rendered. If using insurance, I authorize the release of information necessary for billing purposes.

Signature of Client: By typing my name, I confirm that I have accurately completed this form to the best of my knowledge. *

Date of Signing: *