Pre-Visit Psychiatric Evaluation Intake Questionnaire

Thanks for taking a few minutes before your appointment. These questions help your provider understand what's going on before you meet, and there are no right or wrong answers — honesty helps most. Your responses are completely confidential and anonymized. About 6-8 minutes. This is not a crisis service: if you are in immediate danger, please contact emergency services or a crisis line right now instead of continuing.

In your own words, what's the main concern that brought you to seek this evaluation?

How long have you been dealing with this concern?

• Less than 2 weeks
• 2 weeks to 1 month
• 1 to 6 months
• 6 to 12 months
• More than a year
• This is a recurring issue I've dealt with before

Over the past two weeks, how often have you experienced each of the following?

How much have these concerns interfered with your daily life (work, school, relationships, or self-care) in the last two weeks?

In the past two weeks, how often have you had thoughts that you would be better off dead or of hurting yourself in some way?

• Not at all
• Several days
• More than half the days
• Nearly every day

Are you currently taking any medication prescribed for a mental health condition?

• Yes
• No
• Not sure

Which best describes your prior mental health treatment history?

• No previous treatment
• Outpatient therapy only
• Medication only
• Both therapy and medication
• Inpatient or crisis-level care
• Not sure / prefer not to specify

What are you hoping this evaluation leads to? Select all that apply.

• A clearer understanding of what's going on
• Medication options
• Therapy or coping strategies
• Support during a difficult life event
• A formal diagnosis

Explore the respondent's main presenting concern in depth: when it started, what triggered or worsened it, and what has changed in the last two weeks. If they indicated any thoughts of self-harm as occurring more than 'not at all', gently ask how they are keeping safe right now and clearly note that if they are in immediate danger they should contact emergency services or a crisis line rather than continue. Anchor follow-up on one or two concrete recent examples (a specific day, interaction, or event) rather than general feelings, and note any gap between how they described the problem in their own words and how they rated its severity.

What is your age range? (optional, for clinical context)

• Under 18
• 18-24
• 25-34
• 35-44
• 45-54
• 55-64
• 65 or older
• Prefer not to say

What is your gender identity? (optional, for clinical context)

• Woman
• Man
• Non-binary
• Prefer not to say

Which best describes your current living situation?

• Live alone
• Live with partner or spouse
• Live with family
• Live with roommates
• Other
• Prefer not to say

Thank you for sharing this — your responses will be reviewed by your provider before your appointment to help focus your time together. If anything changes before then, especially around your safety, please reach out to a crisis line or emergency services right away.