Mental Health Intake Form (Page 2 of 4) in pdf

Mental Health Intake Form Page 2

Vittoria Donato Grant, LPC NCC | Trauma & Psychotherapy Associates

Suicide Risk Assessment

Have you ever had feelings or thoughts that you didn’t want to live ( ) YES ( ) NO

If YES, please answer the following. If NO, please skip to the next section.

Do you currently feel that you do not want to live? ( ) YES ( ) NO

How often do you have these thoughts? _________________________________________________

When was the last time you had thoughts of dying? ____________________________________

Has anything happened recently to make you feel this way? ___________________________

On a scale from 1 to 10, (ten being the strongest) how strong is your desire to kill

yourself currently?

Would anything make it better? __________________________________________________________

Have you ever thought about how you would kill yourself?

Is the method you would use readily available?

Have you planned a time for this?

Is there anything that would stop from killing yourself?

Do you feel hopeless and/or worthless?

Have you tried to harm yourself before?

Do you have access to guns?

Medical History

Please list all current prescription medications and how often you take them:

If none, write none

_________________________________________________________________________________________________

Current medical problems:__________________________________________________________________

_________________________________________________________________________________________________

Past medical problems: _____________________________________________________________________

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Mental Health Intake Form Page 2