Mental Health Intake Form printable pdf download

Mental Health Intake Form

Vittoria Donato Grant, LPC NCC | Trauma & Psychotherapy Associates

Mental Health Intake Form

Please complete all information on this form. 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!

Name_____________________________________________________________________Date________________

Address_______________________________________________________________________________________

Phone__________________________________Email_________________________________________________

What are the problem (s) for which you are seeking help?

1)______________________________________________________________________________________________

2)______________________________________________________________________________________________

3)______________________________________________________________________________________________

What are your treatment goals?

Current Symptoms Checklist: (check once for any symptoms present, twice for

major symptoms)

() Depressed mood () Racing Thoughts () Excessive worry

() Unable to enjoy activities () Impulsivity () Panic Attacks

() Sleep Patters Disturbance () Increase Risky Behavior () Avoidance

() Loss of Interest

() Increased Libido () Hallucinations

() Lack of concentration () Decrease need for sleep () Suspiciousness

() Change in appetite () Excessive energy

() Fatigue () Increased Irritability

Mental Health Intake Form