Mental Health Intake & Evaluation Forms
The Mental Health Intake & Evaluation Forms describe background information, basic medical history and current functioning (such as mood and thought processes) needed for the intake process.
Documents are in Microsoft Word (.docx) format. If you need these documents in a different format please contact Andy Benjamin, JD, PhD, ABPP.
| State | File Size |
| Alabama | (docx, 365kb) |
| Alaska | (docx, 365kb) |
| Arizona | (docx, 365kb) |
| Arkansas | (docx, 365kb) |
| California | (docx, 365kb) |
| Colorado | (docx, 365kb) |
| Connecticut | (docx, 365kb) |
| Delaware | (docx, 365kb) |
| Florida | (docx, 365kb) |
| Georgia | (docx, 365kb) |
| Hawai'i | (docx, 365kb) |
| Idaho | (docx, 365kb) |
| Illinois | (docx, 365kb) |
| Indiana | (docx, 365kb) |
| Iowa | (docx, 365kb) |
| Kansas | (docx, 365kb) |
| Kentucky | (docx, 365kb) |
| Louisiana | (docx, 365kb) |
| Maine | (docx, 365kb) |
| Maryland | (docx, 365kb) |
| Massachusetts | (docx, 365kb) |
| Michigan | (docx, 365kb) |
| Minnesota | (docx, 365kb) |
| Mississippi | (docx, 365kb) |
| Missouri | (docx, 365kb) |
| State | File Size |
| Montana | (docx, 365kb) |
| Nebraska | (docx, 365kb) |
| Nevada | (docx, 365kb) |
| New Hampshire | (docx, 365kb) |
| New Jersey | (docx, 365kb) |
| New Mexico | (docx, 365kb) |
| New York | (docx, 365kb) |
| North Carolina | (docx, 365kb) |
| North Dakota | (docx, 365kb) |
| Ohio | (docx, 365kb) |
| Oklahoma | (docx, 365kb) |
| Oregon | (docx, 365kb) |
| Pennsylvania | (docx, 365kb) |
| Rhode Island | (docx, 365kb) |
| South Carolina | (docx, 365kb) |
| South Dakota | (docx, 365kb) |
| Tennessee | (docx, 365kb) |
| Texas | (docx, 365kb) |
| Utah | (docx, 365kb) |
| Vermont | (docx, 365kb) |
| Virginia | (docx, 365kb) |
| Washington | (docx, 365kb) |
| West Virginia | (docx, 365kb) |
| Wisconsin | (docx, 365kb) |
| Wyoming | (docx, 365kb) |
Date created: April 2016