Mental Health Intake Form
A mental health (therapy/counseling) intake form — client and contact details, presenting concerns, mental-health and medical history, current medications, a brief safety check, supports and goals, emergency contact, and consent.
Live preview
MENTAL HEALTH INTAKE FORM
Sample Counseling, LLC
CLIENT INFORMATION
Name: Sample Client DOB: 01/01/1990
Date: May 23, 2026
Contact: (555) 012-3456 · client@example.com
PRESENTING CONCERNS (What brings you in today?)
Increased anxiety and trouble sleeping over the past two months, affecting work and concentration. Would like tools to manage stress.
Duration / frequency: About 8 weeks; most days
MENTAL HEALTH HISTORY (prior therapy, diagnoses, hospitalizations)
Brief counseling in college for stress. No prior diagnoses or hospitalizations.
_________________________________________________
RELEVANT MEDICAL HISTORY
Hypothyroidism (managed). No other chronic conditions.
_________________________________________________
CURRENT MEDICATIONS & SUPPLEMENTS
Levothyroxine 50mcg daily. Occasional melatonin.
SUBSTANCE USE
Alcohol socially (1-2x/week). No tobacco or other substances.
SAFETY CHECK
In the past 2 weeks, have you had thoughts of harming yourself or others?
[ ] No [ ] Yes (if yes, please tell your clinician right away)
* If you are in crisis now, call or text 988 (Suicide & Crisis Lifeline, US)
or call 911 / go to your nearest emergency room.
SUPPORTS & CURRENT COPING
Supportive partner and close friends. Exercises weekly; journaling helps somewhat.
GOALS FOR THERAPY
Reduce anxiety, improve sleep, build coping strategies, and feel more in control.
EMERGENCY CONTACT
Sam Client (spouse) — (555) 987-6543
CONSENT
I confirm the information above is accurate to the best of my knowledge and consent
to participate in services. I understand confidentiality and its legal limits will
be reviewed with me (including mandatory-reporting and safety exceptions).
_____________________________ Date: __________
Client signature (or parent/guardian if a minor)
About this template
A mental health intake form is the structured first step of therapy: it gives a clinician the history and context to understand a client and plan care, and it gives the client a chance to put their concerns into words before the first session. The sections that matter most are the **presenting concerns** (what brings the person in, and for how long), a **mental-health history** (prior therapy, diagnoses, and any hospitalizations), **relevant medical history and current medications** (because physical health, thyroid issues, sleep, and medications can all drive or mimic mental-health symptoms), and **substance use**. Two elements deserve special care. First, a brief **safety check** — a direct question about thoughts of self-harm — because identifying risk early is the single most important function of intake; any "yes" should prompt immediate clinician follow-up, and the form should visibly point to crisis resources (in the US, **988** for the Suicide & Crisis Lifeline, or 911 for emergencies). Second, **consent and confidentiality**: clients should sign consent to treatment, and the clinician should review confidentiality and its **legal limits** (mandatory reporting of abuse, and duty-to-warn/safety exceptions) — these are not optional. Capturing **supports, coping, and goals** rounds out the picture and orients the work toward what the client wants to change. Practically: this is a tool for **licensed providers** to adapt to their setting and state, it must be stored securely and handled under applicable privacy law (in the US, **HIPAA** for covered entities), and it is **not a diagnostic instrument or a substitute for clinical assessment**. Anyone in crisis should not wait for an intake appointment — they should use the crisis resources above immediately.
When to use it
- A licensed therapist/counselor onboarding a new client.
- Collecting history, concerns, medications, and goals before the first session.
- Documenting a brief safety screen and emergency contact.
- Obtaining consent to treatment and reviewing confidentiality limits.
What to include
- Client and contact details, and date.
- Presenting concerns with duration/frequency.
- Mental-health history, medical history, and current medications.
- Substance use, a safety check, supports, coping, and goals.
- Emergency contact and a signed consent.