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An intake form for mental health is the pre-visit and initial-encounter clinical instrument used across outpatient psychiatry, clinical and neuropsychology, and Applied Behavior Analysis (ABA) clinics to collect medical-psychiatric history, standardized symptom severity baselines, safety risk screens, and regulatory consent before formulating a diagnosis and treatment plan. While general outpatient counseling and talk-therapy onboarding are covered in our guide to the therapy intake form (and narrative synthesis in the biopsychosocial assessment template), this guide focuses on the three specialized clinical intake structures—Psychiatric Patient Intake (`CPT 90792`), Clinical & Neuropsychology Intake (`CPT 90791` / `96116` / `96132`), and Applied Behavior Analysis (`ABA`) Intake (`CPT 97151`)—and how they map to the APA DSM-5-TR Cross-Cutting Symptom Measure and HL7 FHIR Questionnaire workflows.
What Should Be Included in an Intake Form for Mental Health? Comparing Psychiatric, Psychology, and ABA Modules
Under American Psychiatric Association (APA) Practice Guidelines for the Psychiatric Evaluation of Adults, American Psychological Association assessment standards, and Behavior Analyst Certification Board (BACB) documentation guidelines, mental health intake forms share a core safety/demographic foundation but diverge sharply across clinical domains based on the billing practitioner’s scope of practice:
| Intake Form Type | Primary CPT Evaluation Code | Specialized Clinical Modules Required on the Intake Form | Core Standardized Screening Instruments |
|---|---|---|---|
| Psychiatric Patient Intake Form (MD / DO / PMHNP / PA) | CPT 90792 (Psychiatric Diagnostic Evaluation with Medical Services) | Lifetime psychotropic medication matrix (drug, max dose, duration, response, discontinuation reason), Tardive Dyskinesia / EPS screen (AIMS), medical/neurological ROS, cardiac/QTc risk history, hepatic/renal/thyroid baseline labs, pregnancy/lactation status | APA DSM-5-TR Level 1 Cross-Cutting Symptom Measure (23 items), C-SSRS (`LOINC 93373-9`), PHQ-9 (`44261-6`), GAD-7 (`69737-5`), MDQ (Bipolar), AUDIT-C / DAST-10 |
| Psychology / Neuropsychology Intake Form (PhD / PsyD) | CPT 90791 (Diagnostic Eval) or CPT 96116 / 96132 (Neurobehavioral Status Exam / Neuropsych Testing) | Educational/IEP/504 accommodations history, developmental and traumatic brain injury (TBI)/concussion history, sleep/cognitive complaint inventory, collateral informant contact authorization, forensic/court-ordered referral exclusions | DSM-5-TR Level 1 & Level 2 PROMIS scales, PCL-5 (PTSD), MoCA / MMSE cognitive screen, WHODAS 2.0 (`LOINC 89213-3` 36-item disability schedule) |
| ABA Intake Form (BCBA / BCBA-D / Licensed Psychologist) | CPT 97151 (Behavior Identification Assessment) & CPT 97152 | Prior Autism Spectrum Disorder (ASD) diagnostic report (ADOS-2 / ADI-R date & diagnosing clinician required by payers), communication modality (vocal, PECS, ASL, SGD/AAC), sensory profile, reinforcer preference inventory, and Antecedent-Behavior-Consequence (ABC) target behavior matrix (elopement, SIB, aggression) | Vineland Adaptive Behavior Scales (Vineland-3), VB-MAPP, ABLLS-R, Essential for Living (EFL), Caregiver Stress Index |
Copy-Ready Psychiatric & Psychology Intake Form Template (CPT 90792 / 90791)
Psychiatry clinics, behavioral health clinics, and psychiatric clinical trial sites can adapt the following modular template to feed the initial psychiatric evaluation and subsequent mental health SOAP note:
SECTION 1: CHIEF COMPLAINT, PRESENTING SYMPTOMS & SAFETY TRIAGE
- Chief Complaint (in patient's own words): "[___________________________________________]"
- Onset, Precipitating Stressors & Functional Impact (Work/School/ADLs/Sleep/Appetite):
[______________________________________________________________________________________]
- Immediate Safety Screen (Columbia-Suicide Severity Rating Scale — C-SSRS Prescreen):
1. Past month wish to be dead (Yes / No) | 2. Non-specific active suicidal thoughts (Yes / No)
3. Active thoughts with any method/intent/plan (Yes / No) | 4. Lifetime suicide attempt (Yes / No)
* Crisis Resource Banner: In the U.S., call or text 988 (Suicide & Crisis Lifeline) or go to the nearest ED.
SECTION 2: PAST PSYCHIATRIC & PSYCHOTROPIC MEDICATION HISTORY (CPT 90792 MODULE)
- Prior Psychiatric Diagnoses: [MDD / Bipolar I-II / GAD / PTSD / OCD / ADHD / Schizophrenia / Other]
- Prior Inpatient Psychiatric Hospitalizations / PHP / IOP / ECT / TMS / Spravato (Dates & Facilities):
[______________________________________________________________________________________]
- Lifetime Psychotropic Medication Trial Matrix:
| Medication Class & Name | Max Daily Dose | Duration | Clinical Response (0-100%) | Side Effects / Reason Stopped |
| SSRI/SNRI: [__________] | [_____ mg/day] | [__ mos] | [None / Partial / Full] | [GI / Activation / Sexual / N/A] |
| Mood Stab/SGA: [______] | [_____ mg/day] | [__ mos] | [None / Partial / Full] | [Weight / Akathisia / Sedation] |
| Stimulant/Other: [____] | [_____ mg/day] | [__ mos] | [None / Partial / Full] | [Insomnia / Tachycardia / N/A] |
SECTION 3: MEDICAL, NEUROLOGICAL, OB/GYN & METABOLIC REVIEW
- Neurological & Endocrine History: [Seizures, TBI/LOC, migraine, thyroid disease, diabetes, dyslipidemia]
- Cardiac History (for QTc/Stimulant Safety): [Personal or family history of sudden cardiac death, arrhythmia, syncope]
- Reproductive / Perinatal Status: [Pregnant / Postpartum / Breastfeeding / Contraception / Last Menstrual Period]
- Recent Lab Results / Vital Signs: [BP, HR, Weight, BMI, Waist Circumference; TSH, CMP, HbA1c, Lipid Panel, UDS]
SECTION 4: SUBSTANCE USE & FAMILY PSYCHIATRIC HISTORY
- Substance Use (Alcohol, Tobacco/Nicotine, Cannabis, Opioids, Stimulants, Sedatives, Caffeine): [Frequency/Route/Last Use]
- Family Biological History: [1st/2nd-degree relatives: Depression, Bipolar, Psychosis, Suicide, AUD/SUD, Dementia]Copy-Ready ABA Intake Form Module (Behavior Identification Assessment — CPT 97151)
For pediatric or adult Applied Behavior Analysis programs, commercial and Medicaid payers require an intake packet that documents medical necessity for a Behavior Identification Assessment (`CPT 97151`) before authorizing ongoing adaptive behavior treatment (`CPT 97153–97158`):
ABA INTAKE SUPPLEMENT (BCBA / CPT 97151 PRE-ASSESSMENT):
1. Diagnostic Eligibility & Medical Clearance:
- Qualifying Diagnosis (ICD-10-CM): [e.g., F84.0 Autistic Disorder] | Date of Comprehensive Dx Eval: [YYYY-MM-DD]
- Diagnosing Physician/Psychologist Name & NPI: [________________________] (Attach ADOS-2 / CDE Report)
- Audiology / Vision / Seizure Action Plan & Allergies/EpiPen Status: [___________________________________]
2. Communication & Adaptive Functioning Profile:
- Primary Expressive Modality: [Vocal sentences / Single words / Echoic / PECS / Sign / Speech-Generating Device (AAC)]
- Receptive Following of 1-Step and 2-Step Instructions: [________________________________________________]
- Daily Living Skills (Toileting, Feeding/Food Selectivity, Dressing, Sleep Hygiene): [___________________]
3. Target Behavior & Antecedent-Behavior-Consequence (ABC) Matrix:
| Target Behavior (Topography) | Estimated Frequency / Duration | Severity (Mild/Mod/Severe) | Common Antecedents (Triggers) | Typical Consequences (How Others Respond) |
| Self-Injurious Behavior (SIB)| [___ episodes/day; ___ min] | [Tissue damage risk: Y/N] | [Task demand / Transition] | [Task removed / Comfort provided] |
| Physical Aggression | [___ episodes/day; ___ min] | [________________________] | [Denied access to preferred] | [Item delivered / Redirection] |
| Elopement / Bolting | [___ episodes/wk] | [Safety hazard: High/Low] | [Loud auditory environments] | [Escorted to quiet area] |
4. Reinforcer & Sensory Preference Inventory:
- High-Preference Tangibles, Edibles, Social Activities & Sensory Inputs: [______________________________]
- Environmental Aversions (Noise, Fluorescent Lighting, Tactile): [______________________________________]How Is a Mental Health Intake Form Structured in EHR Workflows? (DSM-5-TR Level 1 & HL7 FHIR SDC)
Rather than presenting every new patient with 150 static checkboxes, modern behavioral health EHRs implement the American Psychiatric Association’s DSM-5-TR Level 1 Cross-Cutting Symptom Measure (`LOINC 89209-1` for Adults) as an adaptive HL7 FHIR Questionnaire using `enableWhen` conditional branching:
- Stage 1 (DSM-5-TR Level 1 Universal Screen): The adult patient rates 23 brief items across 13 psychiatric domains over the past 2 weeks on a 5-point ordinal scale (`0 = None`, `1 = Slight`, `2 = Mild`, `3 = Moderate`, `4 = Severe`): Depression, Anger, Mania, Anxiety, Somatic Symptoms, Suicidal Ideation, Psychosis, Sleep Problems, Memory, Repetitive Thoughts and Behaviors, Dissociation, Personality Functioning, and Substance Use.
- Stage 2 (`enableWhen` Branching to DSM-5-TR Level 2 / PROMIS Scales): For most domains, a score of `≥ 2` (`Mild` or greater) automatically activates the corresponding Level 2 narrow-band instrument (such as PROMIS Emotional Distress—Depression, PROMIS Anxiety, Altman Self-Rating Mania Scale, or the Florida Obsessive-Compulsive Inventory). Critically, for the high-risk domains of Suicidal Ideation, Psychosis, and Substance Use, a threshold of `≥ 1` (`Slight` or greater) immediately triggers the C-SSRS (`LOINC 93373-9`) or clinician safety review alert.
- Data Segmentation for Privacy (HIPAA Psychotherapy Notes vs. 42 CFR Part 2): Structured mental health intake responses (`QuestionnaireResponse`, diagnostic codes, medication histories, and functional assessment scores) are part of the designated medical record under 45 CFR § 164.501—they are not psychotherapy process notes (45 CFR § 164.508(a)(2)). However, when an intake form is collected by a federally assisted Substance Use Disorder (SUD) program covered by 42 CFR Part 2, the EHR tags the `QuestionnaireResponse` with HL7 Data Segmentation for Privacy (`DS4P`) security labels (`42CFRPart2`) to enforce SUD patient consent rules on downstream health information exchange.
Frequently Asked Questions
What should be included in an intake form for mental health?
A comprehensive mental health intake form captures demographic and insurance data, chief complaint and trauma-informed history, suicide and violence risk triage (C-SSRS), the APA DSM-5-TR Level 1 Cross-Cutting Symptom Measure (23 items across 13 psychiatric domains for adults), and specialty-specific clinical modules: (1) for a psychiatric patient intake form (`CPT 90792`), past psychotropic medication trials, adverse effects, medical/neurological review of systems, and baseline metabolic labs; (2) for a psychology intake form (`CPT 90791`/`96132`), psychodiagnostic and cognitive history; and (3) for an Applied Behavior Analysis (ABA) intake form (`CPT 97151`), developmental milestones, communication modality, sensory profile, and Antecedent-Behavior-Consequence (ABC) functional behavior descriptions.
How is an intake form for mental health structured in EHR workflows?
In behavioral health Electronic Health Record (EHR) systems, mental health intake forms are implemented as HL7 FHIR R4 `Questionnaire` and `QuestionnaireResponse` resources bound to LOINC panel codes (such as LOINC `89209-1` for DSM-5 Level 1 Cross-Cutting symptoms, `44261-6` for PHQ-9, `69737-5` for GAD-7, and `93373-9` for C-SSRS). Conditional `enableWhen` logic dynamically triggers DSM-5-TR Level 2 domain-specific instruments when Level 1 items reach threshold (mild or greater, score $ge 2$), while HL7 Data Segmentation for Privacy (`DS4P`) security labels isolate 42 CFR Part 2 substance-use disorder disclosures and 45 CFR § 164.508(a)(2) psychotherapy notes.
Sources
- American Psychiatric Association (APA). DSM-5-TR Online Assessment Measures (Level 1 Cross-Cutting Symptom Measure, Level 2 Severity Measures, and WHODAS 2.0).
- American Psychiatric Association (APA). Practice Guidelines for the Psychiatric Evaluation of Adults (3rd Edition).
- Behavior Analyst Certification Board (BACB). Applied Behavior Analysis (ABA) Documentation and CPT 97151 Behavior Identification Assessment Standards.
- HL7 International. HL7 FHIR Release 4 — Questionnaire & QuestionnaireResponse Resource Specification.
