Healthcare Template
Free Mental Health Intake Form Template
A mental health intake form collects patient history and consent for therapy services.
Template
Copy this markdown, replace the {{variables}}, and send via API.
# Mental Health Intake Form
**Client:** {{clientName}}
**Therapist:** {{therapistName}}
**Date:** {{date}}
## Presenting Concerns
{{concerns}}
## History
{{relevantHistory}}
## Treatment Goals
{{goals}}
## Confidentiality
{{confidentialityTerms}}
## Consent to Treatment
I consent to participate in therapy and understand the terms above.Send for e-signature
curl -X POST https://signb.ee/api/send \
-H "Authorization: Bearer YOUR_API_KEY" \
-H "Content-Type: application/json" \
-d '{
"content": "YOUR_RENDERED_MARKDOWN",
"senderName": "Your Name",
"senderEmail": "you@company.com",
"recipientName": "Recipient",
"recipientEmail": "recipient@email.com"
}'What happens next
- Signbee converts the markdown to a professional PDF
- Recipient gets an email with a signing link
- Both parties sign with an animated handwriting signature
- Both receive the signed PDF with a SHA-256 certificate
All signatures are legally binding under the ESIGN Act, eIDAS, and ECA.
More details
A mental health intake form serves a dual purpose: it collects clinical information the therapist needs to begin treatment, and it documents the client's informed consent for therapy services. Mental health records have additional legal protections beyond standard medical records.
Why mental health intake is different: Mental health records receive heightened protection under both HIPAA and many state laws. Psychotherapy notes (the therapist's personal observations recorded separately from the medical record) have the strongest protection under HIPAA and require separate authorization for disclosure.
Essential components: 1. Presenting concerns — Why the client is seeking therapy. Current symptoms, their severity, and how long they've been present. 2. Mental health history — Previous therapy, psychiatric hospitalisations, medications (current and past), and diagnoses. 3. Medical history — Physical health conditions that may affect mental health. Current medications. Substance use history. 4. Family history — Mental health conditions in immediate family. Family dynamics relevant to treatment. 5. Risk assessment — Current suicidal ideation, self-harm, homicidal ideation. Safety planning if risk is identified. 6. Treatment goals — What the client hopes to achieve. Collaboratively defined with the therapist.
Confidentiality disclosures specific to mental health: - Mandatory reporting: Therapists must break confidentiality if there's imminent danger to the client or others, suspected child abuse, or elder abuse. - Court orders: Therapists may be compelled to disclose records by court order, though they can advocate for limiting disclosure. - Insurance: If the client uses insurance, diagnosis and treatment codes are shared with the insurer. - Supervision: If the therapist is in training, a supervisor reviews cases. - Couples/family therapy: Confidentiality works differently when multiple clients are in the room.
Frequently asked questions
Are mental health records more protected than regular medical records?
Yes. Mental health records receive additional protections under HIPAA and many state laws. Psychotherapy notes (therapist's personal observations) have the strongest protection and require separate, specific patient authorization for disclosure, even from the treating provider.
When can a therapist break confidentiality?
Therapists must break confidentiality when there is imminent danger to the client or others (duty to warn), suspected child or elder abuse (mandatory reporting), or when compelled by a valid court order. These exceptions should be clearly explained during intake.
Can mental health intake forms be signed electronically?
Yes. Electronic intake forms are valid under ESIGN (US) and eIDAS (EU). Many therapy practices use secure electronic intake systems that comply with HIPAA requirements. The electronic record provides timestamped evidence of informed consent.
Related resources
Send this template for signing — free, no credit card.