Free Mental Health Admission Form Template
Mental Health Admission Form
Please help us serve you better by completing this form with accurate details.
Date
Name
Date of Birth
Gender
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Male
-
Female
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Marital Status
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Single
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Married
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Divorced
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Widowed
-
Address
Phone Number
Emergency Contact Name
Emergency Contact Phone
What brings you in today?
Select all that apply:
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Stress
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Anxiety
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Depression
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Hopelessness
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Have you experienced any of the following?
Select all that apply:
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Difficulty Sleeping
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Loss of Appetite
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Thoughts of Self-harm
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Difficulty Concentrating
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Low Energy
Do you have any diagnosed medical conditions?
If yes, please specify
Current Medications
Preferred Appointment Type
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In-person
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Virtual
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No preference
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