Mental Health New Patient History Form
Personal Information
Full Name
Date of Birth
Gender
Phone Number
Email
Address
Emergency Contact
Name
Relationship
Phone Number
Referral
Referred By
Presenting Concerns
Main reason(s) for seeking help
Mental Health History
Previous diagnoses, hospitalizations, or mental health treatments
Current medications (psychiatric and others)
Family history of mental health concerns
Substance Use
Use of alcohol, tobacco, or other substances
Social History
Occupation / School
Living Situation
Relationship Status
Support System
Medical History
Medical conditions or major illnesses
Allergies