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It gathers demographics, contact information, complaint history, onset and prior treatment, symptom checklists, aggravating and relieving factors, and current medical and psychiatric background. The form also requests medication use, allergies, exercise habits, and family history, including adoption, trauma, abuse, early development milestones, and legal or court-ordered treatment questions.",{"@graph":63,"@context":118},[64,80,101],{"@type":65,"itemListElement":66},"BreadcrumbList",[67,71,74,77],{"item":68,"name":69,"@type":70,"position":9},"https://docshare.wps.com","Home","ListItem",{"item":72,"name":10,"@type":70,"position":73},"https://docshare.wps.com/template/",2,{"item":75,"name":36,"@type":70,"position":76},"https://docshare.wps.com/template/forms/",3,{"item":78,"name":59,"@type":70,"position":79},"https://docshare.wps.com/template/behavioral-health-intake-information-form-intake/307711/",4,{"url":78,"name":59,"@type":81,"image":82,"author":87,"headline":59,"publisher":90,"fileFormat":93,"inLanguage":57,"description":61,"dateModified":94,"datePublished":95,"encodingFormat":93,"isAccessibleForFree":96,"interactionStatistic":97},"DigitalDocument",{"url":83,"@type":84,"width":85,"height":86},"https://docshare.wps.com/thumbnails/behavioral-health-intake-information-form-intake/307711.png","ImageObject",442,249,{"name":88,"@type":89},"Jacob","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-10-22","2026-09-19",true,{"@type":98,"interactionType":99,"userInteractionCount":40},"InteractionCounter",{"@type":100},"ViewAction",{"@type":102,"mainEntity":103},"FAQPage",[104,110,114],{"name":105,"@type":106,"acceptedAnswer":107},"What patient information does the intake form request?","Question",{"text":108,"@type":109},"The form requests name, date, address, phone, email, DOB, sex, and assigned providers such as a primary physician and current therapist.","Answer",{"name":111,"@type":106,"acceptedAnswer":112},"How does the form capture the patient’s behavioral health complaint and symptoms?",{"text":113,"@type":109},"It asks for the major complaint with start date and prior history, then provides a “Current Symptoms” checklist along with space for aggravating and relieving factors.",{"name":115,"@type":106,"acceptedAnswer":116},"What types of medical, family, and early development details are included?",{"text":117,"@type":109},"It includes medical history such as exercise frequency, allergies, medications, diagnoses and surgeries, and it collects family history (adoption, relationships, parental status) plus early development experiences and trauma or abuse history.","https://schema.org",{"og:url":78,"og:type":120,"og:title":59,"og:site_name":91,"og:description":61},"article",{"robots":122,"canonical":78},"index,follow",{"doc_id":124,"site_id":56},307711,1790106565,{"code":4,"msg":5,"data":127},{"doc_id":124,"user_id":128,"nickname":88,"user_avatar":129,"doc_module":9,"category_id":35,"category_name":36,"doc_title":59,"doc_description":61,"doc_content":130,"file_id":131,"file_url":132,"file_type":133,"file_size":134,"view_count":40,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":76,"language":135,"language_code":57,"site_id":56,"html_lang":57,"table_of_contents":136,"faqs":137,"seo_title":138,"seo_description":61,"update_tm":139,"read_time":9},962084931830,"https://ap-avatar.wpscdn.com/davatar_a8503ba1806abce46bf441b54a3ca4cd","Name:   Date:  Address:   Phone:   Email:   DOB:   Sex:   Primary Physician:   Phone:   \nCurrent Therapist:  Phone:   \nComplaint  \nWhat is your major complaint?  Start Date:   Have you previously suffered from this complaint?  Previous therapist(s) seen for complaint:  Previous treatment for complaint:  Aggravating Factors:  Relieving Factors:   \nCurrent Symptoms (Check All That Apply)  \n☐Anxiety  \n☐Appetite Issue  \n☐Avoidance ☐Crying Spells ☐Depression  \n☐Hallucinations ☐Loss of Interest ☐Excessive Energy ☐Fatigue ☐Impulsivity  \n☐Irritability ☐Panic Attacks ☐Racing Thoughts ☐Guilt  \n☐Libido Changes  \n☐Risky Activity ☐Sleep Changes ☐Suspiciousness ☐  \n☐  \nMedical History  \nExercise Frequency:  Exercise Type (s):  Allergies:  What medications are you currently using?   Previous diagnoses/mental health treatment:  Previously treated by:  Previous medications:  Dates treated:  Previous medical conditions:  Previous surgeries:   \nPatient Information  \nBehavioral Health Intake Information Form Department: Behavioral Health  \nC360\\#: 002486  \nDate: 12/23  \nFamily History  \nWere you adopted?  If yes, at what age?   Foster care?   How long?  How is your relationship with your mother?   How is your relationship with your father?   Siblings and their ages:   Are your parents married?  Divorced?  Did your parents remarry?  If yes? How old were you?   If a patient is a minor under 18 years old and parents are divorced, who is medical decision maker?  \nWho raised you?   Where did you grow up?   If patient is a minor under 18 years old, school attending?   grade   special education?  Family member medical conditions:  Family member mental conditions:  Treated with medication?  Medications:   \nEarly Development  \nHow often did you move and where?   How old were you when you left home?   Have any immediate family members died?   Who?   Have any completed suicide?   Who?   Describe any neglect you suffered, and by whom:  Trauma suffered and by whom:  Abuse suffered and by whom:  Highest education level completed:  Date completed and location:  Have you ever served in the military?   If yes, where?  Date of service:   Highest Rank achieved    \nPresent Situation  \nWork: ☐Full-time ☐Part-time ☐Student ☐Unemployed ☐Disabled ☐Retired Are you married?   If yes, date of marriage:  Are you divorced?  If yes, date of divorce:  Prior marriages?  If yes, how many?  What are your preferred pronouns?    \nPatient Information  \nBehavioral Health Intake Information Form Department: Behavioral Health  \nC360\\#: 002486  \nDate: 12/23  \nHow is your relationship with your partner?  Do you have children?   Dates of Birth:  How is your relationship with your child(ren)?  List anyone else who lives with you:   Are you a member of a religion/spiritual group?   What is your level of involvement?   Have you ever been arrested?   When and why?  Are you under court ordered treatment?    \nHave You Ever Tried the Following? (Check All That Apply)  \n☐Heroin ☐Methamphetamines ☐ Cocaine ☐ Stimulants (Pills)  \n☐Ecstasy ☐Methadone ☐Tranquilizers ☐Pain Killers  \n☐Tobacco ☐Marijuana ☐Hallucinogens ☐Alcohol  \nIf yes to any, list frequency/dates of use:  \n____________________________________________________  \nHave you ever been treated for drug/alcohol abuse?   If yes, when?   For which substances?   \nDo you smoke cigarettes?   If yes, how many per day?    \nDo you drink caffeinated beverages?   If yes, how many per day?   Have you ever abused prescription drugs?  If yes, which ones?   \nAnything Else You Want the Doctor to Know  \n\n|  |\n| --- |\n|  |\n|  |\n|  |\n|  |\n|  |\n|  |\n\nSignature   Date   Legal Guardian Name   Signature  Date   \nPatient Information  \nBehavioral Health Intake Information Form Department: Behavioral Health  \nC360\\#: 002486  \nDate: 12/23","cbCaihs2smeYryWk","https://ap.wps.com/l/cbCaihs2smeYryWk","pdf",480062,"English","# Patient Information\n## Complaint and Current Symptoms\n## Medical History\n## Family History\n## Early Development\n## Present Situation\n## Substance Use and Treatment\n## Additional Information & Signatures","[{\"question\":\"What patient information does the intake form request?\",\"answer\":\"The form requests name, date, address, phone, email, DOB, sex, and assigned providers such as a primary physician and current therapist.\"},{\"question\":\"How does the form capture the patient’s behavioral health complaint and symptoms?\",\"answer\":\"It asks for the major complaint with start date and prior history, then provides a “Current Symptoms” checklist along with space for aggravating and relieving factors.\"},{\"question\":\"What types of medical, family, and early development details are included?\",\"answer\":\"It includes medical history such as exercise frequency, allergies, medications, diagnoses and surgeries, and it collects family history (adoption, relationships, parental status) plus early development experiences and trauma or abuse history.\"}]","Behavioral Health Intake Information Form - Intake | PDF",1789853565]