Intake Form - Hopeful Minds Mental Health Clinic LLC

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Intake Form

Intake Form

intake form

Personal Information

Client’s full name

Client’s preferred name

Who is completing this form?

Emergency contact

Full name

Relationship to client

Phone number

Background

Race

Ethnicity

Client’s preferred language

Sexual identity

Relationship status

Home/living situation

Employment/ school status

Therapy goals

In your own words, what is the reason for seeking care currently? Describe any current problems as you see them.

What are your goals for therapy/ what would you like to accomplish?

Health history

Are you currently under treatment for any medical condition?

Yes

No

Do you have any allergies?

Yes

No

Have you had any prior illnesses, operations, or accidents?

Yes

No

Are you currently taking any medications for your mental health?

Yes

No

Do you have a primary care physician?

Yes

No

Do you have a psychiatrist?

Yes

No

Health history

Have you had any prior mental health treatment?

Have you ever been psychiatrically hospitalized?

Do you currently use, or have you previously used any substances?

We believe that mental well-being is the foundation of a fulfilling life. Our mission is to provide high-quality, patient-centered mental health care that empowers individuals to overcome challenges and achieve personal growth.

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Information

(424) 468-2194
(310) 272-9967
info@hopefulmindsmhc.com
11900 S Avalon Blvd S# 100B, Los Angeles, CA 90061

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