What’s Included

• Personal information. The clinic will require the client’s name, gender, marital status, and contact information. This section will also ask the client about any previous counseling, psychiatric treatment, and their medication history.
• General health information. The information provided here includes the client’s present physical health, sleep, eating and exercise habits, and alcohol or substance use.
• Symptoms. The clinic will need to know the client’s mental health issues, including how recently they’ve had symptoms such as depression or suicidal thoughts.
• Family mental health history. This form  is also used to gather information on whether there have been other mental illness diagnoses in the client’s family.
• Personal details. This section covers what the client believes their strengths and weaknesses are, as well as their coping strategies and goals for therapy.
• Acknowledgment. The form must be signed by the client and, if required, their guardian or representative.

Protected Health Information (PHI)

The HIPPA (Health Insurance Portability and Accountability Act) protects patient information (referred to as Protected Health Information provided to a health professional during intake or treatment. Certain exceptions apply, such as:

• If the patient consents to their information being shared.
• If the information is required for a patient’s treatment, service payments, and healthcare operations.
• If it is necessary for preventing harm to the patient or others.
• If disclosing the information is required to comply with a legal investigation.

Furthermore, the SAMHSA’s (Substance Abuse and Mental Health Services Administration) confidentiality regulations provide additional protections for a patient’s substance abuse records and treatment.