Psychology Patient Intake Form
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Psychology patient intake formBest for psychology practices onboarding new patients.
Mental health intake formFor therapy, counseling, and behavioral health intake.
Patient intake formA general healthcare intake form for new patients.
Adult therapy intakeFor adults 18+ starting individual therapy.
ADHD intake formFor ADHD evaluations in children, teens, and adults.
Couples therapy intakeFor couples or partners beginning therapy together.
Psychiatric intakeFor medication management and psychiatric care.
General private practiceA flexible starting point for most practices.
Individual therapy intakeFor one-on-one counseling and psychotherapy.
Family therapy intakeFor families seeking counseling and relationship support.
Marriage counseling intakeFor married couples seeking relationship counseling.
Counseling intake formA general intake form for licensed counselors and therapists.
Psychotherapy Intake Form
We kindly ask your cooperation in answering the questions below as accurately as possible since they will assist your counselor in assessing your needs pre-appointment.
Section 1: Demographics & contact information
Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Cell Phone Number
(000) 000-0000
Please enter a valid phone number.
Home Phone Number
(000) 000-0000
Please enter a valid phone number.
Email
example@example.com
Gender
Please Select▾
Age
ex: 23
Birth Date
MM-DD-YYYY▦
Date
Preferred contact method
PhoneEmailText
Section 2: Emergency contacts & safety
Emergency contact name
Relationship
Emergency contact phone
(000) 000-0000
Please enter a valid phone number.
Would you like to share more about your current wellbeing and safety?
NoYes
If yes, please share what you would like us to know
Are you currently experiencing a crisis or thoughts of harm?
NoYes
Section 3: Safety assessment
In the past two weeks, have you had thoughts of self-harm?
NoA littleOften
Have you ever attempted suicide?
NoYes
Are you currently having thoughts of harming yourself or others?
NoYes
Recent thoughts of suicide or self-harm — please describe
Section 4: Medical & mental health history
Current medical conditions
Past mental health diagnoses
Current medications
Allergies
Section 5: Trauma history
Have you experienced any of the following? (check all that apply)
Physical abuseEmotional abuseSexual abuseNeglectDomestic violenceCommunity violenceSerious accident or injurySudden loss of a loved oneNone of the abovePrefer not to say
Approximate age(s) when this occurred
Have you ever received support or therapy related to these experiences?
YesNo
How do these experiences affect you today?
Section 6: Family & social history
Family mental health history
Relationship / marital status
Living situation
Social support
Were you adopted?
YesNo
Where did you grow up?
List your siblings and their ages
Did your parents divorce?
YesNo
Section 7: Current concerns
What brings you in today?
How long has this been present?
Section 8: Goals for therapy
What are your goals for therapy?
What would a successful outcome look like for you?
Which goal feels most important to start with?
Section 9: Substance use history
Substance use history
Frequency of use
Do you exercise regularly?
YesNo
How much time each day do you exercise?
Have you ever tried any of the following? (check all that apply)
MethamphetamineCocaineStimulants (pills)HeroinLSD or hallucinogensMarijuanaPain killers (not as prescribed)MethadoneTranquilizers / sleeping pillsAlcoholEcstasyOther
Have you ever smoked cigarettes?
YesNo
If yes, how many packs per day?
For how many years?
Other behavioral health information
Section 10: Treatment history & medications
Previous treatment or therapy
Current providers
Current medications
Notes
Section 11: Past psychiatric medications
If you have ever taken any of the following medications, please indicate the dates and daily dosage.
Psychiatric medications you have ever taken
| Have you ever taken it? | Dates | Dosage | Side Effects? | |
|---|---|---|---|---|
| Prozac (fluoxetine) | ||||
| Zoloft (sertraline) | ||||
| Luvox (fluvoxamine) | ||||
| Paxil (paroxetine) | ||||
| Celexa (citalopram) | ||||
| Lexapro (escitalopram) | ||||
| Effexor (venlafaxine) | ||||
| Cymbalta (duloxetine) | ||||
| Wellbutrin (bupropion) | ||||
| Remeron (mirtazapine) | ||||
| Serzone (nefazodone) | ||||
| Anafranil (clomipramine) | ||||
| Pamelor (nortriptyline) | ||||
| Tofranil (imipramine) | ||||
| Elavil (amitriptyline) | ||||
| Tegretol (carbamazepine) | ||||
| Lithium | ||||
| Depakote (valproate) | ||||
| Lamictal (lamotrigine) | ||||
| Topamax (topiramate) | ||||
| Seroquel (quetiapine) | ||||
| Zyprexa (olanzapine) | ||||
| Geodon (ziprasidone) | ||||
| Abilify (aripiprazole) | ||||
| Clozaril (clozapine) | ||||
| Haldol (haloperidol) | ||||
| Prolixin (fluphenazine) | ||||
| Risperdal (risperidone) | ||||
| Ambien (zolpidem) | ||||
| Sonata (zaleplon) | ||||
| Rozerem (ramelteon) | ||||
| Restoril (temazepam) | ||||
| Desyrel (trazodone) | ||||
| Adderall (amphetamine) | ||||
| Concerta (methylphenidate) | ||||
| Ritalin (methylphenidate) | ||||
| Strattera (atomoxetine) | ||||
| Xanax (alprazolam) | ||||
| Ativan (lorazepam) | ||||
| Klonopin (clonazepam) | ||||
| Valium (diazepam) | ||||
| Tranxene (clorazepate) | ||||
| Buspar (buspirone) |
Other medications?
Section 12: Primary care physician
Primary care physician name
Clinic or practice name
Phone Number
(000) 000-0000
Please enter a valid phone number.
May we contact your primary care physician about your care?
YesNo
Section 13: Relationship
What is your relationship status?
MarriedSeparatedWidowedOtherNever MarriedDomestic Partnership
How would you rate your relationship well-being?
12345678910
Not functioningNo problems
Section 14: Employment
What is your employment status?
EmployedRetiredDisabledHomemakerOtherUnemployedSelf-employedStudent
Your average monthly income (USD)
ex: 23
USD
Section 15: Family & household
Including yourself, how many people live in your household?
−1+
Total household monthly income (USD)
ex: 23
USD
Family history of any of the following conditions (check all that apply)
| Yes | No | Indicate Family Member | |
|---|---|---|---|
| Anxiety | |||
| Depression | |||
| Substance abuse / alcohol | |||
| Arrests | |||
| Obesity | |||
| Schizophrenia | |||
| Suicide attempt | |||
| Domestic violence |
Additional comments
How would you rate your family relationship?
12345678910
Not functioningNo problems
Section 16: History
Have you previously received any type of mental health services?
YesNo
If yes, please describe the services you received
Are you currently on psychiatric medication?
YesNo
Section 17: General health information
How would you rate your physical health condition?
12345678910
Very PoorExcellent
How often do you exercise?
12345678910
NoneVery Often
How would you describe your general appetite?
12345678910
Very PoorVery Hungry
How would you describe your stress level throughout the day?
12345678910
Very RelaxedVery Stressed
How would you rate your general happiness and well-being?
12345678910
Very unhappyVery happy
Section 18: Symptoms
Please answer all of the statements below that describe your concerns
I often experience
Fear of many thingsGuiltPanic attacksAvoiding peopleHaving nightmaresAnxiety, nervousnessDiscomfort in social situationsSexual issuesOther
I often have
Suicidal thoughtsMemory problemsSleeping disorderStruggled to explain myself to othersObsessive thoughtsViolent thoughtsStress and tensionMedical concernsFatigueWork problemsOther
I often feel
LonelyEmptySadHopeless about the futureExcessive guiltSuspiciousOther
Section 19: Referral source
How did you hear about us?
Doctor or provider referralFriend or familyInsurance directoryOnline searchSocial mediaOther
Referred by (name, if applicable)
Reason for referral (if applicable)
Section 20: Appointment & availability
Please check your available times for a weekly appointment? (Check as many as applies)
| Monday | Tuesday | Wednesday | Thursday | Friday | |
|---|---|---|---|---|---|
| 9:00 AM - 10:00 AM | |||||
| 10:00 AM - 11:00 AM | |||||
| 11:00 AM - 12:00 PM | |||||
| 1:00 PM - 2:00 PM | |||||
| 2:00 PM - 3:00 PM | |||||
| 3:00 PM - 4:00 PM | |||||
| 4:00 PM - 5:00 PM |
Please book an available time for your first appointment?
06/29/2026▦
9:00 AM - 10:00 AM10:00 AM - 11:00 AM11:00 AM - 12:00 PM1:00 PM - 2:00 PM2:00 PM - 3:00 PM3:00 PM - 4:00 PM4:00 PM - 5:00 PM
Section 21: Insurance status
Do you have insurance?
YesNo
Section 22: Consent, notices & policies
I acknowledge the consent, notices, and office policies provided.
I acknowledge
Signature
Your signature
✕
Printed name
Date signed
MM-DD-YYYY▦
Guardian signature (if under age 18)
Your signature
✕
Guardian printed name
Relationship to patient (if applicable)
Submit