Mental Health Intake Medical History Form
Personal Information
Full Name
Date of Birth
Phone
Email
Address
Emergency Contact
Name
Relationship
Phone
Presenting Concerns
Reason for seeking support
Medical & Mental Health History
Current Medications
Medical Conditions
Past Mental Health Diagnoses / Concerns
Family History of Mental Health Concerns
Lifestyle Information
Substance Use (alcohol, tobacco, drugs)
Sleep Pattern
Exercise
Other Information
Anything else you'd like to share