Mental Health Intake Form

Required for mental health, ketamine, and TMS appointments · Fields marked * are required

Patient Information

First Name*

Last Name*

Date of Birth*

Phone*

Today's Date*

Appointment type*

Chief Complaint

What brings you in today? Describe your main concern.*

How long have you been experiencing these symptoms?

Mental Health History

Prior psychiatric diagnoses

Prior psychiatric medications (include what worked, what didn't, and why stopped)

Prior therapy / counseling

Prior psychiatric hospitalizations

Prior suicide attempts

Prior ketamine or TMS treatment (if any)

Current Symptoms — PHQ-9 (Depression)

Over the last 2 weeks, how often have you been bothered by the following problems?

Current Symptoms — GAD-7 (Anxiety)

Over the last 2 weeks, how often have you been bothered by the following problems?

PTSD & Trauma

Have you experienced a traumatic event?

If yes, briefly describe (optional)

Safety Assessment

Current suicidal ideation*

Current self-harm behaviors*

If you have current safety concerns, please describe

Substance Use

Alcohol use

Cannabis use

Other substance use

Goals for Treatment

What are your goals for this treatment? What would success look like for you?*

I certify that the information provided on this form is accurate and complete to the best of my knowledge. I understand this information will be used to provide appropriate medical care.

I certify the above information is accurate. *

Patient / Guardian Signature (type full name)*

Date*