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Psychological Intake Form Example

The document provides a template for a psychological intake form, including sections for client information, reason for visit, mental health history, medical background, safety and risk assessment, life context, coping skills, payment details, and consent. Each section contains prompts for the clinician to gather essential information about the client's mental health and personal circumstances. The form concludes with spaces for client and clinician signatures to confirm consent and understanding of therapy.

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Mikel Macwan
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4 views2 pages

Psychological Intake Form Example

The document provides a template for a psychological intake form, including sections for client information, reason for visit, mental health history, medical background, safety and risk assessment, life context, coping skills, payment details, and consent. Each section contains prompts for the clinician to gather essential information about the client's mental health and personal circumstances. The form concludes with spaces for client and clinician signatures to confirm consent and understanding of therapy.

Uploaded by

Mikel Macwan
Copyright
© All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd

Psychological Intake Form Example

Here's a psychological intake form template you can use:

Client information

 Name:

 Date of birth:

 Contact details:

 Address:

 Emergency contact (name/relation/phone):

Reason for visit:

Current concerns (check any)

☐ Low mood ☐ Worry ☐ Panic ☐ Trauma stress ☐ Anger/irritability

☐ Sleep trouble ☐ Appetite change ☐ Low energy ☐ Difficulty concentrating

☐ Intrusive thoughts ☐ Avoidance ☐ Compulsions ☐ Hearing/seeing things

Other: __________

Mental health history

 Prior therapy? What helped/didn’t help?

 Past diagnoses or hospital stays?

 Current/past psych medications (name, dose, helpful or not, side effects):

Medical background

 Major health issues or pain:

 Current medications/supplements:

 Alcohol/drug use (type, how often):

Safety and risk assessment

 Thoughts of self-harm? Yes/No

 If yes: plan, intent, access to means?

 Thoughts of harming others? Yes/No

 Feel safe at home? Yes/No

Life context and environmental factors

 Who do you live with?


 Family mental health or substance history:

 Employment status:

 Job satisfaction:

 Military background:

Coping skills and strengths

 How do you typically cope with stress or anxiety?

 Who do you rely on during difficult situations?

Payment

 Insurance company and plan:

 Member ID:

 Self-pay or insurance billing?

Consent

☐ I understand the nature of therapy and its limits.

☐ I understand privacy rules and reporting limits.

☐ I agree to the payment policy.

☐ I consent to treatment.

Client signature: ___________________ Date: __________

Clinician signature: ________________ Date: __________

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