Mental Health Admission Form

Mental Health Admission Form

Please help us serve you better by completing this form with accurate details.

Date

    Name

      Date of Birth

        Gender

          • Male

          • Female

          Marital Status

            • Single

            • Married

            • Divorced

            • Widowed

            Address

              Phone Number

                Email

                  Emergency Contact Name

                    Emergency Contact Phone

                      What brings you in today?

                      Select all that apply:

                        • Stress

                        • Anxiety

                        • Depression

                        • Hopelessness

                        Have you experienced any of the following?

                        Select all that apply:

                          • Difficulty Sleeping

                          • Loss of Appetite

                          • Thoughts of Self-harm

                          • Difficulty Concentrating

                          • Low Energy

                          Do you have any diagnosed medical conditions?

                          If yes, please specify

                            Current Medications

                              Preferred Appointment Type

                                • In-person

                                • Virtual

                                • No preference

                                Admission Form Templates @ Template.net

                                Thank you for filling out this form!

                                We will review the information and contact you shortly.

                                Create free forms at Template.net