Template library · Intake forms
Psychiatry Intake template
Please complete before your psychiatric evaluation.
- 19 fields across 3 sections
- Included with MyWellOps
- Edit it, or save your own version
What’s in it
- DateDate
- PractitionerText
Contact & Insurance
- Full nameText
- Date of birthDate
- Phone numberText
- EmailText
- Emergency contact (name & phone)Text
- Insurance providerText
Psychiatric History
- Reason for seeking psychiatric careText
- OtherText
- Overall mood in the past two weeksText
- Current psychiatric medicationsText
- Prior mental health diagnosesText
- Prior psychiatric hospitalization?Choice
- Current symptoms (check all that apply):
- Anxiety
- Depressed mood
- Sleep disturbance
- Mood swings
- Panic attacks
- Difficulty concentrating
Safety & Family History
- Any current thoughts of self-harm or harming others?Choice
- Current or past substance useText
- Family history of mental illnessText
- Client signatureSignature
- Date signed (client)Date
When to use it
Send an intake form when a new client books, so their history, contact details and reasons for coming are in front of you before the first appointment rather than taken down during it.
How it works in MyWellOps
- Choose it from Documents and adjust the questions to your practice.
- Send it to the client, who completes it in their client portal.
- Their answers are kept on the client’s record, ready for the first session.
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