Psychiatric Evaluations and Medication
Management Virtual Consultation
Client Intake Form
I. Personal Information
First Name
Last Name
Date of Birth
Gender Identity
Preferred Pronouns
Street Address
Street Address Line 2
City
State/Province
Postal/Zip Code
Phone Number
Email Address
Emergency Contact Name
Emergency Contact Phone Number
Preferred Method of Communication
II. Medical History
Do you have any chronic medical conditions?
If yes, please specify:
Are you currently taking any medications?
If yes, please list:
Do you have any allergies (e.g., medications, foods, environmental)?
If yes, please specify:
Have you ever been hospitalized for a medical condition?
If yes, please provide details:
Do you have a primary care physician?
If yes, please provide their name and contact information:
III. Psychiatric History
Have you ever been diagnosed with a mental health condition?
If yes, please specify:
Have you ever received psychiatric treatment (e.g., therapy, counseling, medication)?
If yes, please provide details:
Have you ever been hospitalized for a mental health condition?
If yes, please provide details:
Have you ever experienced suicidal thoughts or attempts?
If yes, please provide details:
Have you ever experienced self-harm behaviors?
If yes, please provide details:
Have you ever experienced trauma or abuse?
If yes, please provide details:
IV. Current Symptoms
What are your primary concerns or symptoms? (Check all that apply)
Depression
Anxiety
Mood swings
Panic attacks
Insomnia
Difficulty concentrating
Irritability
Fatigue
Loss of interest in activities
Appetite changes
Suicidal thoughts
Hallucinations
Paranoia
Other (Please specify):
How long have you been experiencing these symptoms?
How severe are your symptoms on a scale of 1-10? (1 = mild, 10 = severe)
Are these symptoms affecting your daily life (e.g., work, relationships, self-care)?
If yes, please explain:
V. Substance Use History
Do you currently use or have a history of using any of the following?
Alcohol
Tobacco
Marijuana
Prescription drugs (non-prescribed)
Illegal drugs
Other (Please specify):
Have you ever sought treatment for substance use?
If yes, please provide details:
VI. Suitability for Telehealth Services
Do you have access to a reliable internet connection?
Do you have access to a private, quiet space for virtual consultations?
Are you comfortable using video conferencing technology?
Do you have any concerns about using telehealth services?
If yes, please explain:
In case of an emergency, do you have access to local mental health resources?
VII. Psychiatric Evaluation and Medication Options
Psychiatric Evaluations Offered:
Initial psychiatric evaluation
Follow-up psychiatric evaluation
Diagnostic assessment for mood disorders (e.g., depression, bipolar disorder)
Diagnostic assessment for anxiety disorders (e.g., generalized anxiety, panic disorder)
Diagnostic assessment for trauma-related disorders (e.g., PTSD)
Diagnostic assessment for psychotic disorders (e.g., schizophrenia)
Diagnostic assessment for ADHD
Diagnostic assessment for substance use disorders
Other (Please specify):
Medication Management Options:
Antidepressants (e.g., SSRIs, SNRIs, tricyclics)
Anti-anxiety medications (e.g., benzodiazepines, buspirone)
Mood stabilizers (e.g., lithium, valproate)
Antipsychotics (e.g., risperidone, quetiapine)
Stimulants (e.g., methylphenidate, amphetamines)
Non-stimulant ADHD medications (e.g., atomoxetine)
Sleep aids (e.g., trazodone, zolpidem)
Other (Please specify):
VIII. Additional Questions for Client
What are your goals for seeking psychiatric care?
Are there any specific treatments or medications you would like to discuss?
If yes, please specify:
Do you have any preferences or concerns about medications?
If yes, please explain:
IX. Consent for Telehealth Services
I understand that telehealth services involve the use of electronic communications to provide psychiatric evaluations and medication management.
I understand that telehealth services have limitations, including the inability to provide emergency care.
I consent to the use of telehealth services for my psychiatric care.
I understand that I have the right to withdraw consent for telehealth services at any time.
Client Signature:
Client Intake Form Insights
Client Intake Form Insights
Please remove this client intake form insights section before publishing.
This Client Intake Form is a comprehensive tool designed to gather essential information about a client’s mental and physical health, assess their suitability for telehealth services, and establish a foundation for effective psychiatric care. Below is a detailed breakdown of each section and its purpose:
Section 1: Personal Information
Purpose: To collect basic demographic and contact information for identification, communication, and emergency purposes.
Key Insights:
- Knowing the client’s preferred pronouns and communication methods ensures respectful and effective interactions.
- Emergency contact information is critical for safety, especially in telehealth settings where the client may be remote.
Section 2: Medical History
Purpose: To understand the client’s overall health, identify potential contraindications for medications, and assess comorbidities that may impact psychiatric treatment.
Key Insights:
- Chronic medical conditions (e.g., diabetes, heart disease) can influence medication choices (e.g., avoiding weight-gaining medications in diabetic patients).
- Allergies and current medications help prevent adverse drug interactions.
- A primary care physician’s contact information facilitates coordinated care.
Section 3: Psychiatric History
Purpose: To gather information about the client’s mental health background, including diagnoses, treatments, and significant events (e.g., hospitalizations, trauma).
Key Insights:
- Past diagnoses and treatments provide context for current symptoms and guide treatment planning.
- History of suicidal thoughts, self-harm, or trauma highlights areas requiring immediate attention and safety planning.
- Trauma history is essential for trauma-informed care, which avoids retraumatization and fosters trust.
Section 4: Current Symptoms
Purpose: To identify the client’s primary concerns, assess symptom severity, and determine how symptoms impact their daily functioning.
Key Insights:
- Symptom duration and severity help differentiate between acute and chronic conditions.
- Understanding the impact on daily life (e.g., work, relationships) informs treatment goals and prioritization.
- Specific symptoms (e.g., hallucinations, paranoia) may indicate the need for urgent intervention or specialized care.
Section 5: Substance Use History
Purpose: To evaluate the client’s relationship with substances, which can influence psychiatric treatment and medication choices.
Key Insights:
- Substance use can exacerbate mental health symptoms or interact with psychiatric medications.
- A history of substance use disorders may require integrated treatment approaches (e.g., dual diagnosis treatment).
- Past treatment attempts provide insight into the client’s readiness for change and potential barriers to care.
Section 6: Suitability for Telehealth Services
Purpose: To assess whether the client has the necessary resources and comfort level to engage in telehealth services effectively.
Key Insights:
- Access to reliable internet and a private space ensures the client can participate fully in virtual consultations.
- Comfort with technology reduces barriers to engagement and improves the overall telehealth experience.
- Emergency resources are critical for clients in crisis, as telehealth cannot provide immediate in-person intervention.
Section 7: Consent for Telehealth Services
Purpose: To inform the client about the nature, benefits, and limitations of telehealth services and obtain their consent.
Key Insights:
- Clear communication about telehealth limitations (e.g., inability to provide emergency care) sets realistic expectations.
- Obtaining consent ensures the client is fully informed and agrees to the terms of virtual care.
- The right to withdraw consent empowers the client and respects their autonomy.
Section 8: Psychiatric Evaluation and Medication Options
Purpose: To outline the types of evaluations and medications available, helping the client understand what to expect from treatment.
Key Insights:
- Listing specific evaluations (e.g., for ADHD, PTSD) helps tailor the assessment to the client’s needs.
- Providing medication options (e.g., antidepressants, mood stabilizers) educates the client and facilitates shared decision-making.
- Transparency about treatment options builds trust and encourages collaboration.
Section 9: Additional Questions for Client
Purpose: To gather the client’s personal goals, preferences, and concerns, ensuring a client-centered approach to care.
Key Insights:
- Understanding the client’s goals (e.g., symptom relief, improved relationships) helps align treatment with their priorities.
- Preferences or concerns about medications (e.g., fear of side effects) inform personalized treatment plans.
- Open-ended questions allow the client to share additional information that may not fit into structured sections.
Overall Insights into the Form
- Comprehensive Assessment: The form covers all critical areas of mental and physical health, substance use, and telehealth readiness, ensuring a holistic understanding of the client’s needs.
- Client-Centered Care: By including questions about goals, preferences, and concerns, the form prioritizes the client’s voice and promotes shared decision-making.
- Safety and Suitability: Questions about emergency contacts, telehealth resources, and local mental health services ensure the client’s safety and appropriateness for virtual care.
- Efficiency and Clarity: Structured sections and clear questions streamline the intake process, making it easier for both the client and provider to navigate.
- Legal and Ethical Compliance: The consent section ensures compliance with telehealth regulations and ethical standards, protecting both the client and provider.
How to Use the Form Effectively
- For Providers: Use the form to guide initial assessments, identify red flags (e.g., suicidal thoughts, substance use), and develop personalized treatment plans.
- For Clients: Encourage clients to complete the form thoroughly and honestly, emphasizing that their responses will guide their care.
- For Practices: Customize the form to reflect specific practice policies, state regulations, and telehealth platforms.
This form is a powerful tool for delivering high-quality, client-centered psychiatric care in a telehealth setting. It ensures that providers have the information they need to make informed decisions while empowering clients to actively participate in their treatment.
To configure an element, select it on the form.