Mental Health Intake Form

User Guide: Mental Health Intake Form

Overview

This Mental Health Intake Form is designed to collect comprehensive information from clients seeking mental health services. The form is optimized for both digital completion and printing, with a clean, professional design that maintains readability.

How to Use This Form

1. Completing the Form Digitally

• Fill in all relevant fields with your information
• Use the Tab key to navigate between fields
• For checkboxes, click to select all that apply
• For dropdown menus, click to view options and make your selection
• The form does not save data automatically, so consider printing or saving a copy after completion

2. Printing the Form

• Click the "Print Form" button at the top or bottom of the page
• The page will automatically format for printing when using the print button
• Alternatively, use your browser's print function (Ctrl+P or Command+P)
• When printing, only the form content will be printed (the buttons will not appear)

3. Sections of the Form

Personal Information

• Complete all fields with your basic demographic information
• Required fields: First Name, Last Name, Date of Birth, and Contact Information

Emergency Contact Information

• Provide details for someone to contact in case of emergency
• Include their relationship to you and multiple contact methods if possible

Insurance Information

• Provide details of your health insurance coverage
• This information is necessary for billing purposes

Current Concerns

• Describe your primary reason for seeking help
• Check all symptoms that apply to your current experience
• Indicate how long you've been experiencing these symptoms
• Share information about previous mental health treatment

Mental Health History

• Document any previous mental health diagnoses
• List current and past medications
• Share information about previous hospitalizations

Personal History

• Provide background information about family history, relationships, and lifestyle
• This information helps your provider understand your context

Treatment Goals

• Describe what you hope to achieve through therapy/counseling

Consent for Treatment

• Read the consent statements carefully
• Provide your signature and date to consent to treatment

Tips for Completion

1. Be thorough: The more information you provide, the better your mental health provider can understand your needs.
2. Be honest: Accurate information leads to more effective treatment planning.
3. Take your time: There's no need to rush through the form. Complete it when you have sufficient time to provide thoughtful responses.
4. Ask for help: If you have questions about how to complete any section, don't hesitate to ask office staff for clarification.
5. Update regularly: If your circumstances change (medications, contact information, etc.), inform your provider even after submitting this form.

Privacy and Confidentiality

• The information you provide is protected by confidentiality laws
• Your data will only be shared with your treatment team unless you provide written consent for additional sharing
• Exceptions to confidentiality include situations where there is risk of harm to yourself or others

Technical Requirements

• This form works best in modern web browsers (Chrome, Firefox, Safari, Edge)
• JavaScript must be enabled for the print functionality to work
• For optimal printing, use standard 8.5" x 11" paper

Troubleshooting

• If the print button doesn't work, use your browser's print function instead
• If fields appear cut off when printing, check your printer's margin settings
• For other technical issues, consider completing a physical copy of the form at your provider's office

This form is designed to make the intake process as smooth as possible while ensuring your provider has the information needed to deliver appropriate care. If you have any questions or concerns about the form itself, please discuss them with your mental health provider.