Psychiatric intake form
An illustrative outline of the sections a new-patient psychiatric intake commonly covers. Use it to see what a thorough intake includes, then build your own version for your setting.
Current as of July 7, 2026. Laws, payer rules, and billing codes change, so confirm the current requirements for your jurisdiction and setting before you rely on it.
What's inside
Patient and contact information
- Name, date of birth, preferred name and pronouns
- Address, phone, email, emergency contact
- Insurance or payment method (if applicable)
- Primary care physician and referral source
Presenting concern
In the patient's own words: what brings you in today, when it started, and how it affects daily life.
Psychiatric history
- Prior diagnoses, hospitalizations, and outpatient treatment
- Past and current psychiatric medications, response, and side effects
- Prior psychotherapy and what helped
- History of self-harm or suicide attempts
Medical and family history
- Current medical conditions and medications, allergies
- Relevant family psychiatric and medical history
Social history and substances
- Living situation, relationships, work or school, supports
- Alcohol, tobacco, cannabis, and other substance use
- Trauma history, screened sensitively and only as clinically appropriate
Safety screen
A standardized safety screen for suicidal or homicidal ideation, with a clear plan for positive screens. Crisis line: call or text 988 in the US.
Consents referenced
Note where the patient reviews and signs the treatment consent, privacy practices, telehealth consent (if applicable), and financial policy. Keep those as separate signed documents.
About this resource
This template is part of the shrinkiatry resource library, a set of free, clinician-facing references and examples. It's reviewed by Shariq Refai, MD, MBA, FAPA, a board-certified psychiatrist, on a quarterly schedule. Next scheduled review: October 1, 2026. First published July 7, 2026, last reviewed July 7, 2026.
Browse the rest of the resource library, or verify who reviews this site. Spotted something out of date? Email corrections@shrinkiatry.com.