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(443) 544-4673

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Sound Mind Mental Health Services Intake Form

Form Introductory Text

Personal Information

Full Name*

Date of Birth

Gender

Marital Status

Contact Information

Phone Number ✓ Valid

Email Address*

Address

Emergency Contact

Name

Relationship

Phone Number ✓ Valid

Insurance Information

Primary Insurance Provider

Policy Number

Group Number

Policyholder's Name

Policyholder's Date of Birth

Medical and Psychiatric History

Primary Care Physician

Name

Contact Information ✓ Valid

Current Medications

Name

Dosage

Frequency

Prescribing Physician

Allergies

Previous Psychiatric Diagnosis

Diagnosing Clinician

Date of Diagnosis

Previous Psychiatric Medications

Name

Dosage

Frequency

Prescribing Physician

Previous Hospitalizations

Reason

Date

Duration

Any History of Substance Use

Substance

Frequency

Duration

Family History of Psychiatric Conditions

Relationship

Condition

Presenting Concerns

What brings you to seek psychiatric care at this time?

Current Symptoms (please check all that apply)

Depression Anxiety Panic Attacks Mood Swings Suicidal Thoughts Homicidal Thoughts Hallucinations Delusions Sleep Disturbances Appetite Changes Concentration Issues Other

Specify

How long have you been experiencing these symptoms?

Psychosocial History

Education Level

Current Employment Status

Occupation Employer

Living Situation

Alone With Family With Friends Other

Support System

Family Friends Community Other

Significant Life Events (past year)

Legal Issues (if any)

Substance Use History

Type

Frequency

Duration

Daily Habits

Diet

Exercise

Sleep Pattern

Additional Information

Goals for Treatment

Any specific concerns or questions for your provider?

Preferred Pharmacy

Name

Location

Contact Information ✓ Valid

Consent and Confidentiality

I hereby consent to receive psychiatric evaluation and treatment.

Signature

Clear Signature

Date

Confidentiality Agreement

I understand that my information will be kept confidential and shared only with my consent or as required by law

Signature

Clear Signature

Date

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About Us

At Sound Mind, our practice stands firmly at the intersection of science and compassion.

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Contact us

1301 York Rd, Suite 800, Lutherville, MD 21093, USA.

(443) 544-4673

info@soundmindmentalhealthllc.com