Teletherapy Initial Mental Health Screening Form

Personal Information

Full Name Date of Birth Gender Female Male Non-binary Other Prefer not to say Phone Number Email Address

Emergency Contact

Contact Name Relationship Contact Phone

Medical & Mental Health History

Current Medications Medical Conditions Previous Mental Health Diagnosis or Treatment

Present Concerns

Describe current symptoms or concerns How long have you been experiencing these concerns? How are these concerns affecting your daily life?

Risk Assessment

Have you had thoughts of self-harm or suicide? No Yes Have you had thoughts of harming others? No Yes If yes to any above, please provide more information

Consent

I consent to teletherapy and understand the limitations and risks involved.