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
Alabamaopens in new window (docx, 365kb)
Alaskaopens in new window (docx, 365kb)
Arizonaopens in new window (docx, 365kb)
Arkansasopens in new window (docx, 365kb)
Californiaopens in new window (docx, 365kb)
Coloradoopens in new window (docx, 365kb)
Connecticutopens in new window (docx, 365kb)
Delawareopens in new window (docx, 365kb)
Floridaopens in new window (docx, 365kb)
Georgiaopens in new window (docx, 365kb)
Hawai'iopens in new window (docx, 365kb)
Idahoopens in new window (docx, 365kb)
Illinoisopens in new window (docx, 365kb)
Indianaopens in new window (docx, 365kb)
Iowaopens in new window (docx, 365kb)
Kansasopens in new window (docx, 365kb)
Kentuckyopens in new window (docx, 365kb)
Louisianaopens in new window (docx, 365kb)
Maineopens in new window (docx, 365kb)
Marylandopens in new window (docx, 365kb)
Massachusettsopens in new window (docx, 365kb)
Michiganopens in new window (docx, 365kb)
Minnesotaopens in new window (docx, 365kb)
Mississippiopens in new window (docx, 365kb)
Missouriopens in new window (docx, 365kb)
State File Size
Montanaopens in new window (docx, 365kb)
Nebraskaopens in new window (docx, 365kb)
Nevadaopens in new window (docx, 365kb)
New Hampshireopens in new window (docx, 365kb)
New Jerseyopens in new window (docx, 365kb)
New Mexicoopens in new window (docx, 365kb)
New Yorkopens in new window (docx, 365kb)
North Carolinaopens in new window (docx, 365kb)
North Dakotaopens in new window (docx, 365kb)
Ohioopens in new window (docx, 365kb)
Oklahomaopens in new window (docx, 365kb)
Oregonopens in new window (docx, 365kb)
Pennsylvaniaopens in new window (docx, 365kb)
Rhode Islandopens in new window (docx, 365kb)
South Carolinaopens in new window (docx, 365kb)
South Dakotaopens in new window (docx, 365kb)
Tennesseeopens in new window (docx, 365kb)
Texasopens in new window (docx, 365kb)
Utahopens in new window (docx, 365kb)
Vermontopens in new window (docx, 365kb)
Virginiaopens in new window (docx, 365kb)
Washingtonopens in new window (docx, 365kb)
West Virginiaopens in new window (docx, 365kb)
Wisconsinopens in new window (docx, 365kb)
Wyomingopens in new window (docx, 365kb)
Date created: 2016
