A psychiatrist client intake form is used to gather a new patient’s personal and medical information in preparation for an appointment with a psychiatrist. The form asks the patient about their current mental health issues, how they respond to various situations, and their personal and familial psychiatric history. The collected data helps the professional understand the patient’s issues, identify the underlying source, and provide treatment.

Contents Form Overview Personal Info Reasons for Visit Psychiatric History Psychological Assessment Alcohol or Other Drug Use Personal/Family Data Confidentiality and Patient Intake Forms Psychiatrist vs. Psychologist

Form Overview

Personal Info

The patient should state their name, contact information, and whether or not the clinic may leave phone messages.

Reasons for Visit

This section asks the patient about the issues they are facing, anything they’ve done to remedy the problem, and what they are seeking (e.g., therapy, medication, advice, etc.)

Psychiatric History

The patient must specify any history of mental illness diagnoses or treatments and if they’ve taken psychiatric medication or received psychiatric hospitalization.

Psychological Assessment

The psychological assessment is used to examine the following aspects:

• The patient’s current mental and emotional state
• How various situations affect them
• Any symptoms of trauma, suicidal thoughts, or other mental health issues
• Their habits, behavior, and personality

Alcohol or Other Drug Use

The patient will need to describe their current and past alcohol and drug use, specifying how frequently they drink and whether they believe they have an alcohol or drug problem.

Personal/Family Data

The patient’s details, such as marital status, education, profession, and ethnicity, should be provided. The form will also require information about the patient’s family, including any history of mental illness and whether they live with the patient.

Confidentiality and Patient Intake Forms

The Health Insurance Portability and Accountability Act (HIPPA) is a federal law preventing health professionals, including mental health professionals, from disclosing certain health information unless the patient gives consent. Similarly, the Substance Abuse and Mental Health Services Administration has established confidentiality regulations which also protect the privacy of a patient’s substance abuse treatment records.

However, it’s important to note that clinics and professionals may disclose protected information in emergencies to ensure the safety of the patient or others.

Psychiatrist vs. Psychologist

While psychology and psychiatry both address mental health, there are specific differences between the two. Psychiatrists specialize in diagnosing mental illnesses and providing treatment, such as medication or psychotherapy, whereas psychologists or other therapists mainly employ talk or behavioral therapy.