Patient Intake Form · Page 1 of 2 · mindledger.io

Instructions for provider: Share this form with patients before their first appointment. Collect and review before the session.

1. Patient Information

First name

Last name

Date of birth (MM/DD/YYYY)

Phone number

Email address

2. Presenting Concern

Primary concern — what brings you in today? *

Duration of concern

Functional impact on daily life (circle: 0–1–2–3–4–5–6–7–8–9–10)

What prompted you to seek care now?

Treatment goals — what are you hoping to achieve?

3. Mood & Emotional Experience

Select anything that has felt true for you recently:

□ Low mood □ Loss of pleasure □ Anxiety □ Panic □ Irritability □ Racing thoughts □ Detachment □ Unusual thoughts □ Compulsions

Current mood state (circle: Mostly low / Fluctuating / Stable / Elevated)

Persisted > 2 weeks? (Yes / No)

Mood improves with positive events? (Yes / No)

Excessive anxiety? (Yes / No)

4. Fundamental Functions

Sleep patterns — select anything true recently:

□ Trouble falling asleep □ Trouble staying asleep □ Early waking □ Oversleeping □ Irregular schedule □ No issues

Hours of sleep per night (circle: <4 / 4–6 / 6–8 / 8+)

Appetite changes (circle: Decreased / Increased / No change)

Energy patterns — select anything true recently:

□ Low energy □ Fatigued □ Variable energy □ High energy □ No concerns

Patient Intake Form · Page 2 of 2 · mindledger.io

5. Focus & Thinking

Difficulty focusing or staying on task? (Yes / No)

Concentration baseline (circle: Stable / Diminished / Extraordinary / Unsure)

6. Changes in Mood Patterns

Decreased need for sleep but still energetic? (Yes / No) Unusually elevated or energized mood? (Yes / No) Increased drive or productivity? (Yes / No) Out-of-character risk-taking? (Yes / No) Rapid speech or pressure to talk? (Yes / No) Acting more on impulse than usual? (Yes / No)

7. Current Stressors

Select anything currently applicable:

□ Work / school □ Relationship □ Financial □ Housing □ Legal □ Social isolation

8. Substance Use

Judgment-free. Honest answers help your clinician support you best.

Alcohol (circle: None / Occasionally / Weekly / Daily)

Cannabis (circle: None / Occasionally / Weekly / Daily)

Natural stimulants — coffee, energy drinks (None / Occ / Weekly / Daily)

Prescription stimulants (None / Occasionally / Weekly / Daily)

Opioids (circle: None / Occasionally / Weekly / Daily)

Other substances (circle: None / Occasionally / Weekly / Daily)

9. Safety — Review Carefully Before Appointment

Thoughts of not wanting to be alive? (Yes / No) If yes — how often? (Fleeting / Frequent / Persistent) Thoughts of harming yourself or ending your life? (Yes / No) Thought about a specific method? (Yes / No) Currently have a plan? (Yes / No) Intent to act on this plan? (Yes / No) Taken any preparatory steps? (Yes / No) Thoughts of harming someone else? (Yes / No) Specific person identified? (Yes / No) Homicidal plan? (Yes / No)

10. Health & Treatment Background

Chronic medical conditions

Current medications

Current supplements (vitamins, herbs, OTC products, performance enhancers)

Psychiatric medications in past 12 months? (Yes / No)

If yes — experience (circle: Helpful / Not helpful / Side effects)

Additional notes

Want this delivered automatically before every appointment? Sign up free at mindledger.io

Free download

Psychiatric Intake Form Template

A clinically structured, print-ready intake form covering all 10 sections — presenting concern, mood, safety screening, substance use, and treatment history. Free to download and use.

Download free template See the automated version →

✦ Free PDF — no account required

MindLedger Patient Intake Form · 2 pages

1. Patient Information

First name

Last name

2. Presenting Concern

Primary concern — what brings you in today?

9. Safety — Review carefully before appointment

Thoughts of not wanting to be alive? (Yes / No)

Suicidal ideation? (Yes / No)

10. Health & Treatment Background

Current medications

Want this delivered automatically? Sign up free at mindledger.io

What's included

All 10 clinical sections.
Nothing missing.

1–2

Patient info & presenting concern

Name, contact, date of birth, primary concern, duration, functional impact scale, treatment goals, and what prompted care now.

3–4

Mood & fundamental functions

Mood symptom checklist, baseline mood state, sleep patterns, hours per night, appetite changes, and energy patterns.

5–7

Focus, mood patterns & stressors

Concentration difficulty, hypomanic/manic symptom screening — decreased sleep need, elevated mood, impulsivity, rapid speech — and psychosocial stressors.

Substance use

Alcohol, cannabis, natural stimulants, prescription stimulants, opioids, and other substances — frequency for each.

Safety screening

Passive death wish, suicidal ideation, method, plan, intent, preparatory actions, homicidal ideation, specific person, plan, and intent. Clearly marked for clinical review.

Health & treatment background

Chronic conditions, current medications, supplements, prior psychiatric medications, experience with prior meds, and open notes field.

Using this template manually

Print and hand to patient at arrival
Patient fills out by hand in the waiting room
You decipher handwriting before the session
File or scan the paper form yourself
No automatic safety flag alerts
No structured PDF in your inbox
Works — but takes time and friction

Using MindLedger (free to try)

Send your unique link by text or email
Patient completes it before they arrive
Structured clinical PDF arrives in your inbox instantly
Safety flags highlighted automatically
Chart-ready baseline summary — no transcription
First patient submission is completely free
Same 10-section clinical structure as this template