Mental Health Intake Form
Three-page intake for mental health services: presenting concerns, history and support, risk and safety questions, and what the client wants from therapy.
A ready-to-use healthcare & clinical form for small teams who need a reliable intake process: 25 questions, 3 pages, 4 conditional rules.
- Questions
- 25
- Pages
- 3
- Layouts
- classic · card
- Time to complete
- ≈ 10 min
- Conditional rules
- 4
Searches this template answers
- mental health intake form
- mental health assessment form template
- counselling intake form online
- psychiatric intake questionnaire
- therapy assessment form
- new client mental health form
Also filed under
Live preview and test console
This is the real form. Answer it to test the 1 conditional rule — nothing is sent or stored.
Page 1 of 3 — What brings you here
Every question on this page is currently visible.
Compliance checklist
- Payment items priced — passingEvery payment question charges a real amount, so a submission always records a payment.
- Conditional logic resolves — passingEvery rule points at a question or page that exists in this template.
- Medical disclaimer present — passingThis form does not provide medical advice, diagnosis or treatment. Information you share here is not a substitute for care from a qualified clinician. In an emergency, contact your local emergency service immediately.
- Question labels unique — passingLogic and exports address questions by label, so duplicates are ambiguous.
What happens after submit: nothing is stored in this preview. On your own copy, every response triggers an instant email notification and lands in your response dashboard, ready to export or forward.
Happy with it? Take a copy into your workspace — every question, rule and setting comes with it.
Who this template is for
Mental Health Intake Form is built for small teams who need a reliable intake process who need to collect the same complete information from everyone.
- Small teams who need a reliable intake process working in healthcare & clinical.
- Teams who need to collect the same complete information from everyone without writing code or paying for a custom build.
- Anyone replacing chasing missing details over email with one structured record per enquiry.
- Respondents are the people you send it to — the form asks them 25 questions across 3 screens.
- Mobile-heavy audiences, thanks to the one-question-per-screen card layout.
Why this form is useful
It removes the cost of chasing missing details over email and turns each submission into a record your team can act on immediately.
- 14 questions are required, so submissions arrive complete instead of needing a follow-up email.
- It captures a phone number for urgent follow-up.
- It pins the request to a specific date.
- Conditional logic hides 4 questions until they are relevant — shorter forms convert better than long ones.
- Splitting the form across 3 pages keeps each screen short and shows respondents how much is left.
- Every response is stored, searchable and exportable, so nothing depends on one person's inbox.
How to use this template
From copy to live form is a few minutes of work, and every step is reversible.
- 1Press “Use this template” — a fresh copy of Mental Health Intake Form lands in your workspace, ready to edit.
- 2Rename or delete any question, and change what is required. Nothing here is fixed.
- 3Open Notifications and add the email addresses that should be alerted on each submission; add an auto-reply to the respondent if the form collects an email address.
- 4Publish it, then either share the link directly or paste the embed snippet into your site — the embedded form resizes to fit and loads no marketing or advertising trackers.
- 5Watch responses land in Submissions, where you can filter, label and export them to CSV or PDF.
Logic and conditions blueprint
Exactly how this form behaves as it is answered — 4 conditional rules ship with it.
- Features conditional validation: if “Have you had support for this before?” is Yes, “What kind, and did it help?” becomes mandatory before the form can be sent.
- Features conditional validation: if “Are you having thoughts of harming yourself at the moment?” is Yes, “Tell us what you are experiencing” becomes mandatory before the form can be sent.
- Features conditional validation: if “Do you use alcohol or drugs to cope?” is Yes, “What, and how often?” becomes mandatory before the form can be sent.
- Features advanced show logic: if “Is anyone at home relying on you for care?” is Yes, the form dynamically exposes “Who relies on you?”. Otherwise that question never appears.
- All 4 rules are editable in the Logic tab, and the built-in checker warns about rules that contradict each other.
About this template
A mental health intake has to gather a great deal without making a first contact feel like an interrogation, so this form is ordered the way a good first conversation runs. Page one asks what has brought the person to the service now, how long it has been going on, what a difficult day looks like, and what has changed recently — open questions, in their own words, with no scales. Page two covers history and context: previous support and whether it helped, current medication, physical health that affects how they feel, living situation, work or study, and who they can talk to. Page three handles safety directly and plainly, because a form that avoids the subject leaves the service without information it needs before a first appointment: current thoughts of self-harm, past attempts, current use of alcohol or drugs to cope, and whether anyone else is at risk. It closes with what the person wants to be different and what they would like the service to know before they arrive. The form does not screen, score or triage; a practitioner reads every answer.
What this form asks
Every question is editable — rename it, make it optional, or delete it entirely.
Page 1 — What brings you here
- Full namerequired
- Date of birthrequired
- Contact numberrequired
- Is it safe to leave a voicemail on this number?required
- What has brought you to the service now?required
- How long has this been going on?required
- What does a difficult day look like?
- Has anything changed recently?
Page 2 — History and support
- Have you had support for this before?required
- What kind, and did it help?
- Current medication
- Physical health that affects how you feel
- Who do you live with?required
- Work, study or daily routine
- Who can you talk to when things are hard?
- Is anyone at home relying on you for care?required
- Who relies on you?
Page 3 — Safety and goals
- Are you having thoughts of harming yourself at the moment?required
- Tell us what you are experiencing
- Have you ever acted on those thoughts?required
- Do you use alcohol or drugs to cope?required
- What, and how often?
- Is anyone else at risk of harm?required
- What would you like to be different?required
- Anything you would like us to know before we meet
25 questions in total.
Example of a completed mental health intake form
A sample intake showing how a new client describes what has brought them to the service, kept deliberately mundane.
- Full name
- Jordan Pike
- Date of birth
- 07/08/1997
- Is it safe to leave a voicemail on this number?
- Yes
- What has brought you to the service now?
- Feeling low and struggling to concentrate at work for the past couple of months
- How long has this been going on?
- About two months
- Have you had support for this before?
- No
- Who do you live with?
- With a partner
- Are you having thoughts of harming yourself at the moment?
- No
- What would you like to be different?
- To feel more like myself and sleep better
Sample data — no real people, addresses or records are shown. This example gives no clinical advice.
How the form changes as it's filled in
This template ships with 4 conditional rules, grouped into 4 behaviours driven by 4 questions. Everything below is already set up — edit or delete any rule once the template is in your workspace.
Driven by “Have you had support for this before?”
- Makes answers required
If “Have you had support for this before?” is Yes, “What kind, and did it help?” becomes required before the form can be submitted.
Driven by “Are you having thoughts of harming yourself at the moment?”
- Makes answers required
If “Are you having thoughts of harming yourself at the moment?” is Yes, “Tell us what you are experiencing” becomes required before the form can be submitted.
Driven by “Do you use alcohol or drugs to cope?”
- Makes answers required
If “Do you use alcohol or drugs to cope?” is Yes, “What, and how often?” becomes required before the form can be submitted.
Driven by “Is anyone at home relying on you for care?”
- Reveals questions
If “Is anyone at home relying on you for care?” is Yes, the form reveals “Who relies on you?”.
Set it up step by step
- 1
Say who reads it and how quickly
State plainly above the form when a practitioner will read it and what to do meanwhile if something cannot wait; that sentence is not optional on this form.
- 2
Ask about safety directly
Vague wording produces vague answers. Plain questions, with space to explain, give the service what it needs before the first appointment.
- 3
Check the voicemail answer before calling
Contacting someone unsafely is the most avoidable harm a service can do with an intake form, and the answer is right there.
- 4
Read the goal answer first in session
Starting from what the person wants to be different sets the direction of the work far better than reading the history aloud.
Mistakes to avoid
- Skipping safety questions to keep the form gentle, which leaves a practitioner blind at the first appointment.
- Turning open questions into numeric scales, which strips out the detail that shapes the work.
- Leaving intakes unread in a queue when the form implied someone was already looking.
What it pairs with
Most teams don't run this form on its own. These are the forms and systems it sits next to.
What to do with the responses
Have a practitioner read every submission on the working day it arrives, act on the safety answers first, and use the goal answer to open the first session.
Works in both layouts
Forms that overlap this one
These pages cover the same subject ground as the mental health intake form, matched on the words people actually search for.
Therapy Client Intake Form
clientclinicalcoordinatorcounsellinghealth
Therapy Intake Form
assessmentclientconcerncounsellinghealth
Home Health Assessment
assessmentclinicclinicalcoordinatorhealth
Occupational Health Form
assessmentclinicclinicalhealthhistory
Sleep Study Intake Questionnaire
assessmentclinicclinicalcoordinatorhealth
Patient Intake Questionnaire
clinicclinicalhealthhistoryintake
Privacy & compliance
This form collects health information. Keep access limited to the people who need it, turn on encrypted answers for the clinical questions, and set a retention window so records don't sit in the dashboard forever.
Frequently asked questions
How is this different from the Therapy Client Intake Form?
That one is a shorter counselling intake for private practice. This is the fuller service-level assessment, with the history, context and safety sections a multi-practitioner team needs.
Should the form triage or score answers?
No. It records what the person reports; every decision about urgency and suitability belongs with a practitioner reading the whole submission.
What if someone discloses immediate risk?
Your service needs a documented route for that before the form goes live, including who is notified and what happens outside working hours. Say those hours in the intro.
Can it be completed with a practitioner instead?
Yes. Some people would rather answer these questions aloud, and the same form works as a structured first-conversation record.
Is the Mental Health Intake Form template free to use?
Yes. You can preview and test Mental Health Intake Form on this page without an account, and take a copy into your own HelloForms workspace on the free plan. There is nothing to install and no card required to publish it.
What does the Mental Health Intake Form template ask for?
It asks 25 questions across 3 pages, 14 of which are required. Every question is listed in full further down this page, and each one can be renamed, reordered, made optional or deleted after you copy the template.
Can I edit the Mental Health Intake Form form after copying it?
Yes — the copy is entirely yours. Change wording, add or remove questions, switch between the classic and card layouts, restyle it to match your brand, and set who gets notified on each submission.
How does the conditional logic in this healthcare & clinical form work?
4 conditional rules ship with the template: Features conditional validation: if “Have you had support for this before?” is Yes, “What kind, and did it help?” becomes mandatory before the form can be sent. Features conditional validation: if “Are you having thoughts of harming yourself at the moment?” is Yes, “Tell us what you are experiencing” becomes mandatory before the form can be sent. Features conditional validation: if “Do you use alcohol or drugs to cope?” is Yes, “What, and how often?” becomes mandatory before the form can be sent. All rules are editable in the Logic tab.
Where do responses to the Mental Health Intake Form form go?
Submissions land in your workspace under Submissions, where you can search, filter, label and export them to CSV or PDF. You can also email a notification to your team on every submission and send the respondent an auto-reply.
Can I embed the Mental Health Intake Form form on my own website?
Yes. Publish the form and paste the embed snippet into any page or share the direct link. The embedded form resizes to fit its container and loads no advertising or marketing trackers inside the iframe.
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