Mental Health Intake Assessment
Client Information
Full Name
Date of Birth
Age
Gender
Phone Number
Email
Address
Emergency Contact
Name
Relationship
Phone Number
Presenting Issues
Description
Mental Health History
Previous Diagnoses
Past Treatments or Hospitalizations
Current Medications
Family Mental Health History
Family History
Substance Use
Substances Used
Risk Assessment
Suicidal or Homicidal Thoughts/History
Additional Information
Strengths & Supports
Goals for Treatment