Psychiatry Intake Forms & Client Questionnaires

A psychiatric intake is not a therapy intake with medication questions tacked on. Psychiatrists are diagnosing and prescribing, and the information they need before that first appointment is fundamentally different from what a therapist or counselor collects. A therapy intake focuses on presenting concerns, coping strategies, and therapeutic goals. A psychiatric intake focuses on symptom patterns, medication history, physiological factors, and differential diagnosis — because the difference between prescribing an SSRI, an SNRI, a mood stabilizer, or an antipsychotic depends on a clinical picture that cannot be assembled from a generic mental health questionnaire.

The Psychiatry intake form is built for the way psychiatric practices actually evaluate new patients. It captures the chief complaint in the patient’s own words, the duration and onset of current symptoms, what prompted them to seek psychiatric care now (as opposed to six months ago when the symptoms may have started), and who referred them — primary care physician, therapist, emergency department, family member, or self-referral. Each referral source tells the psychiatrist something different: a PCP referral for treatment-resistant depression means first-line medications have already failed, and the intake needs to capture exactly which ones, at what doses, for how long, and why they were discontinued.

Medication History and Prior Treatment Response

The medication history section is the clinical core of a psychiatric intake, and it requires a level of detail that no generic health form provides. The form captures every current psychiatric medication: name, dosage, frequency, prescribing provider, start date, and the patient’s subjective assessment of whether it is helping. It then captures prior medication trials — every psychiatric medication the patient has taken in the past, the maximum dosage reached, the duration of the trial, the reason for discontinuation (ineffective, side effects, cost, non-compliance, provider change), and which specific side effects were experienced. A patient who discontinued sertraline at 50 mg after two weeks due to nausea had an inadequate trial. A patient who took sertraline at 200 mg for six months with partial response and sexual side effects had an adequate trial with a documented side effect profile. The prescribing decision is completely different in those two scenarios, and the intake form needs to capture enough detail to distinguish them.

The form also records non-psychiatric medications, over-the-counter supplements, herbal remedies, and recreational substances, because drug interactions are a constant concern in psychiatric prescribing. An SSRI prescribed to a patient already taking tramadol risks serotonin syndrome. Lithium prescribed to a patient on an ACE inhibitor requires closer monitoring. St. John’s Wort interacts with nearly every psychiatric medication. These details must be captured at intake, not discovered after the first adverse reaction.

Psychiatric History and Diagnostic Screening

The psychiatric history section goes beyond “have you been treated for a mental health condition before.” It captures prior diagnoses (and who made them), psychiatric hospitalizations (dates, facilities, reasons for admission, length of stay), emergency department visits for psychiatric crises, prior suicide attempts (number, method, medical severity, and whether they were treated), history of self-harm, and history of violence or aggression toward others. It includes a developmental history section covering birth complications, developmental milestones, childhood behavioral problems, learning disabilities, and ADHD symptoms in childhood — because adult ADHD, bipolar disorder, and PTSD can present with overlapping symptoms, and the developmental history helps narrow the differential.

The form includes structured screening sections for the major diagnostic categories: mood disorders (depression, mania, hypomania, mixed states, seasonal pattern, postpartum onset), anxiety disorders (generalized anxiety, panic attacks, social anxiety, specific phobias, OCD features), psychotic symptoms (hallucinations by modality, delusions by type, disorganized thinking, paranoia), trauma-related symptoms (intrusive memories, avoidance, hypervigilance, dissociation, nightmares), and cognitive concerns (memory impairment, concentration difficulty, confusion, executive dysfunction). Each section uses checkbox grids with severity and frequency qualifiers rather than yes/no questions, giving the psychiatrist a clinical snapshot before the patient walks through the door.

Substance Use and Family Psychiatric History

Substance use assessment in a psychiatric intake is not a moral inventory — it is a clinical necessity because substance use disorders co-occur with psychiatric conditions at extremely high rates, and active substance use changes every prescribing decision. The form captures use of alcohol, cannabis, opioids (prescription and illicit), stimulants (prescription and illicit), benzodiazepines (prescription and illicit), hallucinogens, inhalants, and nicotine/vaping. For each substance, it records frequency of use, quantity, age of first use, whether the patient considers it a problem, history of withdrawal symptoms, and prior treatment (detox, rehab, MAT, 12-step). This is essential information: prescribing a benzodiazepine for anxiety to a patient with an undisclosed alcohol use disorder is dangerous, and prescribing a stimulant for ADHD to a patient with active cocaine use is clinically contraindicated.

Family psychiatric history is equally critical because psychiatric conditions have strong genetic components. The form captures psychiatric diagnoses in first-degree relatives (parents, siblings, children) and second-degree relatives (grandparents, aunts, uncles), including mood disorders, psychotic disorders, substance use disorders, suicide, ADHD, autism spectrum disorder, and intellectual disability. A patient presenting with a first episode of depression whose mother and maternal grandmother both had bipolar disorder is at elevated risk for bipolar disorder, and prescribing an antidepressant without a mood stabilizer could trigger a manic switch. The family history section captures exactly this type of clinically actionable information.

Intake vs. Client Questionnaire

The intake form is the internal clinical document. The psychiatrist or intake coordinator fills it out during the initial evaluation, recording the clinical history, mental status examination findings, diagnostic impressions, and the initial treatment plan. It includes fields for functional status (GAF or WHODAS), insurance and prior authorization details, and provider notes on clinical complexity and risk level. The companion client questionnaire is what the practice sends to the patient before the first appointment. It asks the patient to describe their current symptoms, list all medications and supplements, provide their psychiatric and medical history, complete family history, answer substance use screening questions, identify emergency contacts, and state their treatment goals. The questionnaire includes HIPAA acknowledgment and consent to treatment. Sending this before the appointment means the psychiatrist spends the evaluation session asking follow-up questions and conducting the mental status exam rather than collecting basic history.

Pricing

Each form is $19.99 for the complete set (intake + questionnaire), $14.99 for intake only, or $9.99 for questionnaire only. All PDFs are fillable in Adobe Reader and password-protected against editing.

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