[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"doc-seo-307665-105":3,"detail-sidebar-cat-1-en-105":81,"doc-detail-307665-en":126},{"code":4,"msg":5,"data":6},0,"ok",{"site_id":7,"language":8,"slug":9,"title":10,"keywords":11,"description":12,"schema_data":13,"social_meta":74,"head_meta":76,"extra_data":78,"updated_unix":80},105,"en","mental-health-intake-form-new-patient-psychiatric-intake","Mental Health Intake Form - New Patient Psychiatric Intake","","Mental health intake questionnaire for new patients seeking care, collecting demographics, primary care physician contact permission for updates, current symptoms and treatment goals, and a suicide risk assessment including ideation frequency, intent strength, access to lethal means, and protective factors. It also gathers current therapists, symptom severity checklists, medication and supplement lists, medical problems, gynecological information for women, past medical and psychiatric history, hospitalization and outpatient treatment details, and prior psychiatric medication responses and side effects.",{"@graph":14,"@context":73},[15,34,56],{"@type":16,"itemListElement":17},"BreadcrumbList",[18,23,27,31],{"item":19,"name":20,"@type":21,"position":22},"https://docshare.wps.com","Home","ListItem",1,{"item":24,"name":25,"@type":21,"position":26},"https://docshare.wps.com/template/","Template",2,{"item":28,"name":29,"@type":21,"position":30},"https://docshare.wps.com/template/forms/","Forms",3,{"item":32,"name":10,"@type":21,"position":33},"https://docshare.wps.com/template/mental-health-intake-form-new-patient-psychiatric-intake/307665/",4,{"url":32,"name":10,"@type":35,"image":36,"author":41,"headline":10,"publisher":44,"fileFormat":47,"inLanguage":8,"description":12,"dateModified":48,"datePublished":49,"encodingFormat":47,"isAccessibleForFree":50,"interactionStatistic":51},"DigitalDocument",{"url":37,"@type":38,"width":39,"height":40},"https://docshare.wps.com/thumbnails/mental-health-intake-form-new-patient-psychiatric-intake/307665.png","ImageObject",442,249,{"name":42,"@type":43},"Maeve","Person",{"url":19,"name":45,"@type":46},"DocShare","Organization","application/pdf","2026-10-22","2026-09-19",true,{"@type":52,"interactionType":53,"userInteractionCount":55},"InteractionCounter",{"@type":54},"ViewAction",11,{"@type":57,"mainEntity":58},"FAQPage",[59,65,69],{"name":60,"@type":61,"acceptedAnswer":62},"What information does this intake form collect before the first visit?","Question",{"text":63,"@type":64},"It collects patient identity details, date of birth, primary care physician information, consent for ongoing updates, current therapist information, and prompts about problem areas, treatment goals, and symptoms.","Answer",{"name":66,"@type":61,"acceptedAnswer":67},"How does the form assess suicide risk?",{"text":68,"@type":64},"It asks about unwanted thoughts of not living, current feelings of not wanting to live, timing of last dying thoughts, triggers, the strength of suicidal desire on a 1–10 scale, access to lethal means, planning and availability of a method, and protective factors.",{"name":70,"@type":61,"acceptedAnswer":71},"What medical and medication history details are requested?",{"text":72,"@type":64},"It requests a list of current prescription medications and dosage frequency, over-the-counter medications or supplements, current medical problems, and—if applicable—pregnancy and birth control questions. It also asks about past medical issues, EKG history, and past psychiatric hospitalizations, outpatient treatment, and prior psychiatric medication responses and side effects.","https://schema.org",{"og:url":32,"og:type":75,"og:title":10,"og:site_name":45,"og:description":12},"article",{"robots":77,"canonical":32},"index,follow",{"doc_id":79,"site_id":7},307665,1790210141,{"code":4,"msg":82,"data":83},"success",[84,88,93,98,103,108,112,117,122],{"id":55,"doc_module":22,"doc_module_name":25,"category_name":85,"show_sort_weight":86,"slug":87},"Presentations",90,"presentations",{"id":89,"doc_module":22,"doc_module_name":25,"category_name":90,"show_sort_weight":91,"slug":92},12,"Resumes",80,"resumes",{"id":94,"doc_module":22,"doc_module_name":25,"category_name":95,"show_sort_weight":96,"slug":97},14,"Invoices",70,"invoices",{"id":99,"doc_module":22,"doc_module_name":25,"category_name":100,"show_sort_weight":101,"slug":102},15,"Posters",60,"posters",{"id":104,"doc_module":22,"doc_module_name":25,"category_name":105,"show_sort_weight":106,"slug":107},16,"Social Media",50,"social-media",{"id":109,"doc_module":22,"doc_module_name":25,"category_name":29,"show_sort_weight":110,"slug":111},17,40,"forms",{"id":113,"doc_module":22,"doc_module_name":25,"category_name":114,"show_sort_weight":115,"slug":116},18,"Letters",30,"letters",{"id":118,"doc_module":22,"doc_module_name":25,"category_name":119,"show_sort_weight":120,"slug":121},21,"Paper Templates",5,"papers-templates",{"id":123,"doc_module":22,"doc_module_name":25,"category_name":124,"show_sort_weight":4,"slug":125},158,"General","general-158",{"code":4,"msg":82,"data":127},{"doc_id":79,"user_id":128,"nickname":42,"user_avatar":129,"doc_module":22,"category_id":109,"category_name":29,"doc_title":10,"doc_description":12,"doc_content":130,"file_id":131,"file_url":132,"file_type":133,"file_size":134,"view_count":55,"is_deleted":4,"is_public":22,"is_downloadable":22,"audit_status":22,"page_count":135,"language":136,"language_code":8,"site_id":7,"html_lang":8,"table_of_contents":137,"faqs":138,"seo_title":139,"seo_description":12,"update_tm":140,"read_time":30},5909877438554,"https://ap-avatar.wpscdn.com/avatar/5600025385ad2bf12a7?_k=1778553567797529272","Name  \nDate of Birth                        Primary Care Physician  \nWhat are the problem(s)for which you are seeking help?  \nWhat are your treatment goals?  \n()Depressed mood()Unable to enjoy activities()Sleep pattern disturbance()Loss of interest  \n()Concentration/forgetfulness()Change in appetite()Excessive guilt()Fatigue()Decreased libido  \nSuicide Risk Assessment  \n# Mental Health Intake Form\n\nPlease complete all information on this form and bring it to the first visit.It may seem long,but most ofthe questions require only a check,so it will go quickly.You may need to ask family members about the familyhistory.Thank you!  \n                                       Date              \nDo you give permission for ongoing regular updates to be provided to your primary care physician?          \nCurrent Therapist/Counselor                          Therapist's Phone                          \n\n| 1.                                     _  _   |\n| --- |\n| 2._____  _   |\n| 3.________   |\n\nCurrent Symptoms Checklist:(check once for any symptoms present,twice for major symptoms)  \n()Racing thoughts()Impulsivity  \n()Increase risky behavior()Increased libido()Decrease need for sleep()Excessive energy()Increased irritability()Crying spells  \nHave you ever had feelings or thoughts that you didn't want to live?()Yes()No.If YES,please answer the following.If NO,please skip to the next section.Do you currently feel that you don't want to live?()Yes()NoHow often do you have these thoughts?                                                      \nWhen was the last time you had thoughts of dying?                                                      Has anything happened recently to make you feel this way?                                \nOn a scale of 1 to 10,(ten being strongest)how strong is your desire to kill yourself currently?              Would anything make it better?                                                                \nHave you ever thought about how you would kill yourself?                                      Is the method you would use readily available?                                                Have you planned a time for this?                                                              \nIs there anything that would stop you from killing yourself?                                      Do you feel hopeless and/or worthless?                                                        Have you ever tried to kill or harm yourself before?                                                      \nDo you have access to guns?If yes,please explain.                                                  \n                                        \n()Excessive worry  \n()Anxiety attacks  \n()Avoidance  \n()Hallucinations  \n()Suspiciousness  \n().           \n().          \n              List ALL current prescription medications and how often you take them:(if none,write none)Medication NameTotal Daily DosageEstimated Start DateCurrent over-the-counter medications or supplements:                                                    Current medical problems:                                                                                                For women only:Date of last menstrual period      Are you currently pregnant or do you think youmight be pregnant?()Yes()No.Are you planning to get pregnant in the near future?()Yes()NoBirth control method                   How many times have you been pregnant?                                   How many live births?                  YouFamilyWhich Family Member?WThyroid Disease-------------------  ()()Anemia---------------------------   ()()Liver Disease------------------------  ()()Chronic Fatigue--------------------  ()()Kidney Disease---------------------  ()()Diabetes----------------------------  ()()Asthma/respiratory problems------  ()()Stomach or intestinal problems ---  ()()Cancer(type)----------------------   ()()Fibromyalgia--------------------  ()()Heart Disease------------------------  ()()Epilepsy or s","cbCaikTwDf23JVUR","https://ap.wps.com/l/cbCaikTwDf23JVUR","pdf",1455753,7,"English","# Mental Health Intake Form\n## Personal Information and Permissions\n## Current Symptoms and Treatment Goals\n## Suicide Risk Assessment\n## Medications and Medical History\n## Past Psychiatric History and Treatments\n## Past Psychiatric Medications","[{\"question\":\"What information does this intake form collect before the first visit?\",\"answer\":\"It collects patient identity details, date of birth, primary care physician information, consent for ongoing updates, current therapist information, and prompts about problem areas, treatment goals, and symptoms.\"},{\"question\":\"How does the form assess suicide risk?\",\"answer\":\"It asks about unwanted thoughts of not living, current feelings of not wanting to live, timing of last dying thoughts, triggers, the strength of suicidal desire on a 1–10 scale, access to lethal means, planning and availability of a method, and protective factors.\"},{\"question\":\"What medical and medication history details are requested?\",\"answer\":\"It requests a list of current prescription medications and dosage frequency, over-the-counter medications or supplements, current medical problems, and—if applicable—pregnancy and birth control questions. It also asks about past medical issues, EKG history, and past psychiatric hospitalizations, outpatient treatment, and prior psychiatric medication responses and side effects.\"}]","Mental Health Intake Form - New Patient Psychiatric Intake | PDF",1789852821]