Mental Health Intake

Please complete this form to the best of your ability.

Adult Registration Intake Form

Adult Registration Intake Form

Please complete all information on this form and bring it to your first visit. It may seem long, but most of the questions require only a check, so it will go quickly. You may need to ask family members about the family history. 

Suicide Risk Assessment

Past Medical History:

Women Only

Personal and Family Medical History:

You may need to ask family members

Past Psychiatric History:

Past Psychiatric Medications:

Indicate if you have ever taken any of the following medications.


Your Exercise Level

Family Psychiatric History:

Substance Use:

Family Background and Childhood History:

Education & Occupational History:

Relationship History and Current Family:

Legal history:

Spiritual History:

Sign Here
Sign Here