Perinatal Mental Health Assessment Intake Form
Demographic Information
Full Name
Date of Birth
Phone Number
Email Address
Address
Obstetric/Medical History
Current Pregnancy Status
Pregnant
Postpartum
Gestational Age (weeks) / Postpartum (weeks)
Number of Pregnancies
Complications (Current or Past)
Mental Health History
Current Symptoms
Previous Mental Health Diagnoses
Current Medications
Previous Therapy or Counseling
Psychosocial Assessment
Support System
Current Stressors
Substance Use (Tobacco, Alcohol, Drugs)
History of Domestic Violence
Risk Assessment
Any Current Thoughts of Self-harm or Suicide?
No
Yes
Any Intent to Harm Others?
No
Yes
If Yes, Please Provide Details
Other Notes
Additional Information