Postpartum Depression Intake Form
Personal Information
Full Name
Date of Birth
Phone Number
Email Address
Address
Pregnancy & Birth Details
Due Date
Delivery Date
Type of Delivery
Vaginal
Cesarean
Assisted
Other
Any Complications During Birth?
Baby’s Health After Birth
Mental Health Assessment
Have you felt sad, down, or hopeless most days in the past two weeks?
Yes
No
Have you lost interest or pleasure in doing things you usually enjoy?
Yes
No
Have you experienced feelings of anxiety, worry, or panic?
Yes
No
Are you experiencing trouble sleeping (even when the baby is asleep)?
Yes
No
Have you had thoughts of self-harm or harming your baby?
Yes
No
Other comments regarding mood, anxiety, or any concerns:
Support & History
Who is your primary support person?
Do you feel supported at home?
Yes
No
Have you experienced postpartum depression before?
Yes
No
History of mental health conditions (personal or family)?
Any additional information you'd like to share?