By the Templateez Team · Licensed Attorney · June 2026

Psychiatry Intake Forms: What Every Psychiatric Practice Needs to Capture at New Patient Intake

A psychiatry intake is not a therapy intake with a prescription pad. It is a medical evaluation that drives diagnostic formulation, risk stratification, and treatment planning — often for patients presenting in crisis, with complex medication histories, and with safety concerns that require immediate assessment. The information a psychiatric practice captures before or during the first appointment determines whether the clinician can prescribe safely, identify risk factors that demand urgent intervention, and build a treatment plan grounded in the patient's full clinical picture rather than a fifteen-minute conversation.

Most general-purpose medical intake forms miss the domains that matter most in psychiatry: prior suicide attempts, medication trials and failures, substance use with withdrawal history, family psychiatric genetics, and the layered consent requirements that govern behavioral health records. A purpose-built psychiatry intake form captures all of this in a structured format that the clinician can review before the patient sits down. Here is what that form should include.

Presenting complaint: the chief concern in the patient's own words

Every psychiatric evaluation begins with why the patient is seeking care right now. Not a diagnostic label — the patient's own language for what is wrong, what prompted them to schedule this appointment, and what they want help with. Your intake form should capture:

• Chief concern in the patient's own words — an open text field, not a checkbox list. "I can't stop thinking about dying" and "I've been feeling a little down" both fall under "depression," but they represent entirely different clinical urgencies. The patient's language is diagnostic data.
• Symptom duration — when did the current episode start? Is this the first time, or is this a recurrence of something the patient has experienced before? Duration shapes the differential. Two weeks of depressed mood after a job loss is an adjustment disorder. Two years of persistent low mood is a different diagnosis with different treatment implications.
• Severity and impact on functioning — is the patient still working? Attending school? Maintaining relationships? Able to perform basic activities of daily living — bathing, eating, sleeping on a regular schedule? A patient who reports anxiety but is functioning well at work needs a different treatment approach than one who has not left their apartment in three weeks.
• Precipitating events — what changed? A relationship ending, a death in the family, a job loss, a new medical diagnosis, a medication change, a substance use relapse. Precipitants are clinically relevant because they inform both diagnosis and the urgency of intervention.

Psychiatric history: the foundation of the diagnostic formulation

Psychiatry is one of the few medical specialties where the patient's treatment history is as diagnostically important as the current presentation. A patient presenting with depressed mood who has had three prior manic episodes is not a major depressive disorder patient — regardless of what they were previously diagnosed with. Your intake needs to capture a thorough psychiatric history:

• Prior diagnoses — every psychiatric diagnosis the patient has received, from whom, and when. Include diagnoses the patient disagrees with or that were later revised. A prior bipolar diagnosis that was "changed to depression" by a different provider is a red flag, not a resolution.
• Prior hospitalizations — inpatient, partial hospitalization (PHP), and intensive outpatient (IOP). For each: the facility, the approximate date, the presenting issue, the length of stay, and whether the admission was voluntary or involuntary. Hospitalization history is one of the strongest predictors of future acute decompensation.
• Prior suicide attempts — number, method, approximate date, and lethality of each attempt. A patient with three prior overdose attempts has a fundamentally different risk profile than a patient with no history. Method is clinically significant because prior method predicts future method, and high-lethality methods (firearms, hanging, jumping) carry different intervention requirements than lower-lethality methods.
• Prior self-harm — non-suicidal self-injury (cutting, burning, hitting) distinct from suicide attempts. Frequency, method, most recent episode, and whether the self-harm is current or historical. Self-harm is a risk factor for future suicide attempts, but it is also a separate clinical issue that requires its own treatment approach.
• Prior treatment providers — therapists, psychiatrists, primary care physicians prescribing psychiatric medications. Names and approximate dates of treatment. This allows the new clinician to request records and understand the patient's treatment trajectory.

Current medications: what the patient is taking, what they have tried, and what went wrong

Medication management is the core clinical function of psychiatric practice, and the intake medication review is the most consequential section of the form. A prescriber who does not know what the patient has already tried, what failed, and why it failed will repeat mistakes that have already been made — costing the patient months of ineffective treatment and avoidable side effects.

• Current psychiatric medications — name, dose, frequency, prescribing physician, and how long the patient has been on each medication. Include PRN medications (as-needed benzodiazepines, sleep aids).
• Current non-psychiatric medications — everything else the patient takes, including over-the-counter supplements, hormonal contraceptives, and herbal products. Drug interactions in psychiatry are clinically significant. An SSRI combined with tramadol creates serotonin syndrome risk. Lithium levels are affected by NSAIDs and ACE inhibitors. St. John's Wort interacts with nearly every psychiatric medication.
• Medication history — prior psychiatric medications, the dose reached, the duration of the trial, the reason it was discontinued (ineffective, side effects, cost, patient preference), and whether it provided any benefit. This is one of the most time-consuming sections for the patient to complete, and one of the most valuable for the clinician. A patient who has failed three SSRIs at adequate doses and duration needs a different strategy than a first-episode patient.
• Allergies and adverse reactions — true allergies (anaphylaxis, rash, angioedema) versus side effects the patient found intolerable (weight gain, sexual dysfunction, sedation). The clinical response to "I'm allergic to Zoloft" depends entirely on whether the reaction was hives or nausea.
• Adherence patterns — does the patient take medications as prescribed? Do they skip doses, take extra doses, run out early, or stop medications without telling their provider? Non-adherence is one of the most common reasons psychiatric medications "fail," and understanding the patient's relationship with medication compliance informs the treatment plan.

Safety assessment: the section that cannot wait

Every psychiatric intake must include a structured safety assessment. This is not optional, and it is not something that can be deferred to the first appointment. If a patient discloses active suicidal ideation with a plan on the intake form, the practice needs to know before the scheduled appointment — and ideally before the patient leaves the waiting room.

• Suicidal ideation — structured screening that distinguishes passive ideation ("I wish I wouldn't wake up") from active ideation ("I've been thinking about killing myself"), and active ideation from ideation with plan, intent, and access to means. Each level requires a different clinical response. The Columbia Suicide Severity Rating Scale (C-SSRS) provides a validated framework for this screening.
• Homicidal ideation — thoughts of harming others, with the same gradient: passive thoughts, active ideation, specific target, plan, and intent. Tarasoff duty-to-warn obligations are triggered by specific, credible threats against identifiable individuals. Your intake form is where these disclosures first surface.
• Access to firearms or other lethal means — does the patient own firearms? Are they stored in the home? Are they locked? Is ammunition stored separately? Means restriction is one of the most evidence-based suicide prevention interventions, and it starts with knowing what the patient has access to.
• Self-harm urges — current urges to engage in self-injury, distinct from suicidal ideation. Frequency, intensity, most recent episode.
• Command hallucinations — if the patient reports auditory hallucinations, are the voices telling them to harm themselves or others? Command hallucinations with violent content represent an acute safety concern that changes the urgency of the evaluation.
• Recent losses or acute stressors — recent death of a loved one, relationship dissolution, job loss, legal trouble, financial crisis, housing instability. Acute psychosocial stressors are among the strongest proximal risk factors for suicide, particularly in combination with a psychiatric history.

This section overlaps with what mental health counseling practices capture at intake, but psychiatric safety assessments carry additional weight because the prescribing clinician must factor safety findings into medication decisions — a suicidal patient should not receive a 90-day supply of a lethal-in-overdose medication with no follow-up interval.

Medical history: the body affects the brain

Psychiatry sits at the intersection of medicine and mental health, and the medical history section reflects that dual role. Psychiatric symptoms can be caused by medical conditions, and psychiatric medications carry medical risks that must be monitored:

• Chronic medical conditions — diabetes, hypertension, thyroid disease, autoimmune conditions, cardiovascular disease. Hypothyroidism mimics depression. Hyperthyroidism mimics anxiety and mania. Uncontrolled diabetes complicates antipsychotic prescribing.
• Neurological conditions — seizure history (lowers the threshold for bupropion and clozapine contraindications), traumatic brain injury (changes the risk profile for impulsivity and mood instability), dementia or cognitive decline (affects medication metabolism and adherence capacity).
• Sleep patterns — insomnia, hypersomnia, sleep apnea, circadian rhythm disruption. Sleep disturbance is both a symptom of nearly every psychiatric disorder and an independent risk factor for worsening mental health. Untreated sleep apnea causes cognitive and mood symptoms that will not respond to psychiatric medication.
• Pain — chronic pain conditions, current pain level, pain medications including opioids. Chronic pain and psychiatric illness are deeply comorbid, and opioid use affects treatment planning across multiple dimensions.
• Pregnancy and nursing status — for patients of childbearing potential. Many psychiatric medications are teratogenic (valproate, lithium, certain benzodiazepines), and pregnancy changes the risk-benefit calculus for every prescription decision.
• Metabolic baseline — weight, BMI, fasting glucose, lipid panel, and hemoglobin A1c. Second-generation antipsychotics carry significant metabolic risk (weight gain, dyslipidemia, insulin resistance, diabetes). A baseline before initiating these medications is standard of care, and the intake form is where you flag whether recent labs are available or need to be ordered.

Family psychiatric history: genetics inform prescribing

Psychiatric illness runs in families, and family history is one of the strongest diagnostic tools available in psychiatry — particularly for bipolar disorder, schizophrenia, and substance use disorders. Your intake should capture first-degree relatives (parents, siblings, children) with:

• Psychiatric diagnoses — depression, bipolar disorder, schizophrenia, anxiety disorders, ADHD, personality disorders, eating disorders. A patient presenting with depression whose mother and brother both have bipolar disorder is a patient who needs careful monitoring for mania if started on an antidepressant.
• Suicide completions — family history of completed suicide is an independent risk factor for suicide in the patient. First-degree relative completions carry the highest risk.
• Substance use disorders — family history of alcoholism or drug addiction informs both the patient's own substance use risk and prescribing decisions around controlled substances.
• Response to specific medications — pharmacogenomically relevant. If the patient's father responded well to sertraline for depression, or their sister had a severe reaction to lamotrigine, these data points inform prescribing decisions. Medication response is heritable, and family medication history is a practical proxy for pharmacogenomic testing in routine clinical practice.

Social history: context for clinical decision-making

Psychiatric treatment does not happen in a vacuum. A brilliant medication regimen fails if the patient is homeless and cannot refrigerate their injectable medication, or if they have no transportation to follow-up appointments, or if their domestic partner is sabotaging their treatment. Social history provides the context that makes treatment plans realistic:

• Living situation — alone, with family, with roommates, in a shelter, in a group home, in a sober living facility, homeless. Housing stability directly affects treatment adherence and crisis planning.
• Employment and disability status — currently working, unemployed, on short-term or long-term disability, receiving SSI/SSDI. Employment status affects insurance, medication access, and functional assessment.
• Legal issues — pending charges, probation or parole, court-ordered treatment, custody disputes, restraining orders. Legal involvement affects treatment planning and may impose reporting requirements.
• Support system — who does the patient have? Family involvement, friends, faith community, peer support. A patient in crisis with a strong support system has different safety planning options than an isolated patient with no one to call.
• Trauma history — adverse childhood experiences (ACEs), physical abuse, sexual abuse, emotional abuse, neglect, witnessing domestic violence, community violence. Trauma history informs diagnosis (PTSD, complex PTSD, dissociative disorders) and affects the therapeutic approach and medication tolerability.
• Military service — branch, dates, deployment history, combat exposure, military sexual trauma, discharge status. Veterans have access to VA healthcare and may have service-connected disabilities that affect treatment coordination.

Substance use: screening, current use, and medication-assisted treatment history

Substance use is comorbid with psychiatric illness at rates far exceeding the general population. Approximately half of individuals with a serious mental illness also have a substance use disorder. Your intake must go beyond "do you drink alcohol — yes or no":

• Standardized screening — AUDIT-C for alcohol (three questions, validated, takes under a minute) and DAST-10 for drugs. These screens provide a quantified risk level that guides the depth of further assessment.
• Current substance use — for each substance: substance, route of administration, frequency, quantity per use, date of last use, and withdrawal history. Alcohol withdrawal can be life-threatening. Benzodiazepine withdrawal can cause seizures. Opioid withdrawal, while not typically fatal, affects medication decisions and timing.
• Medication-assisted treatment (MAT) history — prior or current treatment with methadone, buprenorphine (Suboxone), or naltrexone (Vivitrol). MAT interacts with prescribing decisions (naltrexone blocks opioid pain medications; buprenorphine has drug interaction profiles that must be considered; methadone affects QTc interval in combination with certain psychiatric medications).

Functional assessment: where the patient is right now

Diagnosis tells you what is wrong. Functional assessment tells you how impaired the patient is — and that distinction drives treatment intensity. A patient with moderate depression who is still working full-time and maintaining relationships may be appropriate for outpatient medication management. A patient with moderate depression who has stopped going to work, is not eating, and has not showered in a week may need a higher level of care.

• GAF-equivalent assessment — while the Global Assessment of Functioning has been removed from the DSM-5, the concept of a single-number functional score remains clinically useful. The WHODAS 2.0 is the current recommended replacement. Whatever scale your practice uses, the intake should capture a baseline.
• Work, school, and social functioning — is the patient performing at their expected level? Have they missed work or school? Have they withdrawn from social activities? Are relationships deteriorating?
• Activities of daily living (ADL) capacity — bathing, grooming, dressing, eating, managing medications, managing finances, maintaining the home. ADL impairment indicates a severity level that may warrant a higher level of care, home health support, or involvement of family or social services.

Insurance and prior authorization: the administrative reality

Psychiatry has more prior authorization burden than nearly any other medical specialty. Stimulants, antipsychotics, brand-name medications, and even some generic psychiatric medications require prior authorization from insurance. Your intake form should capture the information your billing staff needs to start this process immediately:

• Insurance information and behavioral health carve-out — many insurance plans use a separate behavioral health administrator (Optum, Carelon, Evernorth). The patient's medical insurance card may not be the card your billing team needs. Capture the behavioral health plan separately.
• Formulary and step therapy requirements — has the patient's insurance required them to try and fail generic alternatives before covering a brand-name medication? If the patient has already failed two generics, that documentation supports a prior authorization for the brand-name option.
• Prior authorization status for current medications — if the patient is transferring care, are their current medications authorized under their plan? A patient who arrives at a new practice on a medication that requires prior authorization may face a gap in coverage while the new provider submits the authorization. Identifying this at intake prevents the patient from running out of medication.

Consent, HIPAA, and the unique protections for behavioral health records

Psychiatric records carry additional legal protections that do not apply to general medical records. Your intake consent process must address these explicitly:

• 42 CFR Part 2 — federal regulations governing the confidentiality of substance use disorder records. These records cannot be disclosed without specific, written patient consent — even to other healthcare providers, even under a general HIPAA authorization. If your practice treats co-occurring substance use disorders, your consent forms must comply with Part 2, and your intake must capture the patient's authorization preferences.
• Psychotherapy notes protections — under HIPAA, psychotherapy notes (the clinician's private process notes) receive heightened protection and generally cannot be disclosed without specific patient authorization, separate from the general treatment authorization. State law may provide additional protections. Your intake should distinguish between authorization to release treatment records and authorization to release psychotherapy notes.
• Telehealth consent — if your practice offers telehealth, informed consent for telehealth services must be obtained at intake. This includes disclosure of the technology platform, the risks of electronic communication, the limitations of remote assessment (particularly for safety evaluation), and the patient's location at the time of the session (which determines which state's laws apply).

For a deeper look at the HIPAA compliance requirements that apply across all healthcare intake documentation, see our guide to HIPAA-compliant intake forms.

Building the clinical relationship from the first document

A comprehensive intake form serves a purpose beyond data collection. For many psychiatric patients, the intake form is the first interaction with a new provider — and for patients who have had negative experiences in the mental health system, that first impression matters. A form that asks thoughtful, clinically relevant questions signals that this practice understands psychiatric care. A form that asks the patient to list their medications and check a box for "depression" signals that this practice treats psychiatric patients the way an urgent care treats a sore throat.

The thoroughness of the intake also protects the clinician. Prescribing psychiatric medications without knowing the patient's suicide attempt history, current substance use, medication trial history, or pregnancy status is a liability exposure that no practice should accept. The intake form is the documentation that you asked the right questions before you wrote the first prescription.

If you are building documentation across a behavioral health practice that includes both prescribers and therapists, the Healthcare Bundle includes psychiatry alongside 20 other healthcare categories, each with specialty-specific intake fields.