Mental Health & Wellness Intake Form

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Mental Health & Wellness Intake Form

First name

Last name

Birthday

Month

Day

Year

Gender Identity

Phone

Address

Multi-line address

Country/Region

Address

City

Zip / Postal code

Preferred contact method

How would you describe your current emotional state?

Have you been feeling any of the following?

Anxiety or Panic

Depression or Deep Sadness

Trouble Sleeping

Lack of Motivation

Overwhelming Anger

Trauma Flashbacks

Feelings of Hopelessness

Mood Swings or Irritability

Isolation

Suicidal Thoughts

None of the Above

Have you ever received mental health treatment before?

Yes

Are you currently taking any medication for mental health?

Yes

Are you open to any group sessions?

Individual Only

Group Only

Both

Not sure yet

What's currently causing you the most stress?

Do you feel supported by family, friends, or community?

Yes

Are there any past events you feel are affecting your mental health today?

Are you currently in a crisis or experiencing suicidal thoughts?

Yes

If you answered YES above, please tell us what you’re experiencing or write ‘HELP’, a team member will follow up immediately.”

Do you permit C.R.I.P.S. to contact you about mental health services and referrals?

Yes

I consent to being contacted by C.R.I.P.S. for wellness support and guidance.

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