Veterans Mental Health Intake Form
Personal Information
First Name
Last Name
Date of Birth
Gender
Male
Female
Non-binary
Other
Prefer not to say
Phone Number
Email Address
Home Address
Military Service
Branch of Service
Years of Service
Discharge Status
Combat Experience (if any)
Mental Health History
Presenting Concerns
Previous Psychiatric Diagnoses
Current Medications
Current Suicidal Thoughts/Behaviors
Previous Psychiatric Hospitalizations
Substance Use History
Support and Resources
Support Network
Other Resources Used