Mental Health Intake Assessment
Personal Information
Full Name
Date of Birth
Gender
Female
Male
Other
Phone
Email
Address
Emergency Contact
Name
Relationship
Phone
Presenting Problems / Concerns
Please describe your main concerns
Mental Health History
Previous mental health diagnosis or treatment
Current medications
Substance use history (if any)
Medical History
Relevant medical conditions
Allergies
Family History
Mental health issues in family
Social History
Current living situation
Support system
Occupation/School
Risk Assessment
Thoughts of self-harm or suicide
Thoughts of harming others
Additional Notes