Geriatric Mental Health Intake Form
Patient Information
First Name
Last Name
Date of Birth
Age
Gender
Male
Female
Other
Prefer not to say
Address
Phone
Email
Emergency Contact
Name
Relationship
Phone
Medical & Mental Health History
Primary Diagnosis
Current and Past Medical Conditions
Mental Health History
Current Medications (Include dosage and frequency)
Allergies
Primary Care Physician
Physician Phone
Physician Address
Presenting Concerns
Please describe the main concerns leading to this appointment
How long have these concerns been present?
Recent Life Changes or Stressors
Previous Psychiatric or Psychological Treatment (include dates and providers)
Function & Support
Living Situation
Support System (family, friends, caregivers)
Assistance with Daily Living (ADLs/IADLs)
Additional Notes