Mental Health Beneficiary Intake Form
Personal Information
First Name
Last Name
Date of Birth
Gender
Male
Female
Non-binary
Prefer not to say
Other
Contact Number
Email Address
Address
Emergency Contact
Name
Relationship
Contact Number
Mental Health History
Reason for Seeking Services
Any Current or Past Mental Health Diagnoses
Current Medications
Previous Mental Health Treatment
Additional Information
Relevant Medical Conditions
Therapy Goals / Expectations
Other Information