Intake Questionnaire for New Patients (Adult)

This questionnaire is for the purpose of getting to know you better in order to provide the best possible mental health services. Please complete this form as honestly and completely as possible. All information that you provide us will be confidential as required by state and federal law. A History Intake Form with the following Headings: I. Contact Information - Name - Date of Birth - Address - Phone Number - Email II. Reason for Seeking Help - What brings you here today? - What are your goals for seeking help? III. Medical History - List any medical conditions or illnesses - List any medications or supplements you are currently taking IV. Mental Health History - Have you ever received mental health treatment before? If so, please describe. - Have you ever been diagnosed with a mental health condition? If so, please specify. V. Family History - List any mental health conditions or illnesses in your family VI. Social History - Education level - Employment status - Marital status - Social support system VII. Substance Use History - Do you use alcohol or drugs? If so, please specify. VIII. Additional Information