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Mental Health Intake

Mental Health Intake Form

This intake helps our nurse practitioners understand what you're going through so we can match you with the right support. Your answers are reviewed by our care team, and someone will reach out to you personally within one business day.

Your Information

Full name *

Email *

Phone

Date of birth

Emergency contact name

Emergency contact phone

What Brings You In

What are you struggling with right now? *

How long have you been feeling this way? *

Have you reached out to anyone about what you're going through?

What You've Been Experiencing

Check anything that applies to you right now.

What You've Tried So Far

Have you previously sought mental health support?

What coping strategies have you tried?

What has helped, if anything?

What has not helped?

Your Support System

Do you have people you feel comfortable talking to?

Who is in your support system?

Mental Health History

Previous diagnoses (if any)

Previous treatment history

Family history of mental health?

Current medications

Current Stressors

Check anything that is adding pressure right now.

Any recent significant life changes?

Safety Screening

In the past two weeks, have you had thoughts of harming yourself? *

Have you ever attempted to harm yourself?

Do you currently have a plan to harm yourself?

Anything Else

Is there anything else you'd like us to know?

Preferred contact method

Best time to reach you

Your intake will be reviewed by our care team. A nurse practitioner will reach out within one business day. If you are in crisis, call or text 988 now.

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