Mental Health Intake Form
Therapeutic Medical and Psychiatric Services

Please complete all information on this form and bring it to the first visit. It may seem long, but most of the questions require only a check, so it will go quickly. You may need to ask family members about the family history. Thank you!

Suicide Risk Assessment

If YES, please answer the following.

If NO, please skip to the next section.

Past Medical History

FOR WOMEN ONLY

Personal and Family Medical History

Past Psychiatric History:

Past Psychiatric Medications: If you have ever taken any of the following medications, please indicate the dates, dosage, and how helpful they were (if you can't remember all the details, just type what you do remember).

Therapy/Counseling History:

Your Exercise Level:

Family Psychiatric History:

Substance Use:

Tobacco History:

Family Background and Childhood History:

Trauma History:

Educational History:

Occupational History:

Relationship History and Current Family:

Legal History:

Spiritual Life:

For Office Use Only: