As a mental health provider, you rely heavily on effective documentation, such as onboarding, charting, evaluations, treatment plans, and follow-up notes. Such mental health forms play a crucial role in delivering care, fulfilling protocols, and providing the best patient outcomes possible. However, if you endeavor to create all of the necessary forms from scratch, it can quickly become both overwhelming and time-consuming. Luckily, most of these important behavioral health intake & assessment forms have become standardized, and are available for any mental health provider to access and use via various software tools. In this article, we will explore the most utilized forms, their benefits, and why you might choose to use them in your practice. 

Essential forms for managing a mental health private practice

There are several types of key forms essential for the daily operations of your mental health practice, from therapy intake forms to mental health assessments and more. These forms are standardized for all patients, unlike clinical forms that cater to specific patient needs and practice specialties.

Consent for Services and Fee Agreement Form

This form grants permission for treatment and also details the practice’s fees for behavioral health services, ensuring transparency and accountability from the outset. Your consent form(s) should include:

• Self-pay rates for various therapies, taking into consideration different durations and clinician experience levels.
• Self-pay fees for commonly used insurance codes.
• Cancellation and no-show fees.
• Information relevant to out-of-network “superbill” insurance reimbursements.

This therapy intake form also helps provide good-faith estimates to comply with the federal No Surprises Act (2022). Some practices may choose to separate Consent for Services into an independent form.

Release of Information (HIPAA) Form

Also known as the Notice of Privacy Practices, this federally required mental health intake form explains the use and disclosure of protected health information. This form must include:

• Written or electronic acknowledgment of receipt from the patient.
• The effective date (date of acknowledgment from the patient).

Cancellation Policy Form

This form is one of the most critical in reducing the amount of late cancellations, no shows, and the subsequent loss of revenue as a result of cancellations. Establishing this policy also gives you the ability to enforce late cancellation fees, which typically include a set rate (i.e. $50) or even cover the entire session. Keep this form clear and straightforward, and ensure it is signed and dated by the patient. This form should include: 

• Expectations for timely attendance.
• Policies for rescheduling and exceptions for extenuating circumstances.
• Penalties to be enforced, such as cancellation fees. 

No-Show Policy Form

While this can be included in the Cancellation Policy form, a separate No-Show Policy form can:

• Clarify the difference between cancellations and no-shows.
• State the no-show fee, which is typically higher and not covered by insurance.
• Specify that treatment may be discontinued after a certain number of no-shows (e.g. 2 or 3).

→ Pro Tip: Automate appointment reminders via text and email to reduce the number of no-shows. 

Auto-Payment Agreement Form

This behavioral health intake form simplifies the payment process for co-payments, co-insurance, and self-pay patients. It should include:

• Permission to securely store payment details (e.g. credit card, debit card, bank draft) to prevent delays in payment. 
• Integration with a patient portal in advanced electronic health record (EHR) systems for online payments.

This is particularly beneficial for telehealth practices as patients don’t experience the typical experience of checking out post-appointments. 

Consent to use Electronic Communication

This legally required form protects your practice when communicating with patients via text message, telephone, and email. Although not required for communicating pertinent medical information, having this form reduces liability for:

• Broadcast messages.
• Appointment and paperwork reminders.
• Other communications.

Ensuring these forms are in place helps streamline operations, maintain compliance, and enhance patient communication in your mental health practice.

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The importance of mental health intake forms for practices

Mental health intake forms are vital for practices as they streamline the initial data collection process, allowing therapists to gather comprehensive background information efficiently. These behavioral health  forms typically include personal information, medical and mental health history, current symptoms, medication usage, family history, and lifestyle factors. This thorough initial evaluation ensures that therapists have a complete picture of the patient's needs from the outset, facilitating more tailored, focused, and effective care.

By using standardized mental health intake forms, therapists can ensure that they have all the necessary information to prepare for the initial session. This preparation is crucial for developing personalized treatment plans and tailoring therapy to address the patient's specific needs. 

→ Pro Tip: Leverage your practice management software to automate the onboarding process, and use smart fields to have onboarding forms auto-populate patient charts. This eases upfront administration and therefore allows you to see patients for their initial appointment sooner. 

Types of mental health forms for your practices

Mental health practitioners use various assessment forms to document patient information and track progress. Charting, intake, and assessment forms serve different purposes in this process.

Charting forms

Charting forms are used to record ongoing notes and updates during the course of a patient's treatment. These forms typically include:

• Session Notes: Detailed notes from each therapy session, including the patient's progress, issues discussed, therapeutic interventions used, and any changes in treatment plans.
• Progress Notes: Summaries of a patient's progress over time, highlighting improvements, setbacks, and adjustments to treatment.
• Medication Records: Documentation of any medications prescribed, including dosages, administration schedules, and patient responses.
• Treatment Plans: Updates and revisions to the patient's treatment plan based on their progress and any new developments

The primary goal of charting is to maintain a detailed and organized record of the patient's ongoing care, ensuring continuity and quality of treatment.

Intake forms

Intake forms are completed at the beginning of the therapeutic relationship and are used to gather comprehensive information about the new patient. These forms generally include:

• Demographic Information: Basic details such as the patient’s name, age, gender, contact information, and emergency contacts.
• Medical History: Information about the patient’s past and current medical conditions, medications, and any previous mental health treatments.
• Psychosocial History: Background information on the patient's social, familial, educational, and occupational history, as well as significant life events.
• Reason for Seeking Treatment: The patient's primary concerns, symptoms, and goals for therapy.

The purpose of therapy intake forms is to provide the practitioner with a thorough understanding of the patient's background and current situation, forming the foundation for the initial assessment and treatment planning.

Assessment forms

Behavioral health assessment forms are used to evaluate a patient's mental health status at specific points in time. They help in diagnosing conditions, tracking changes over time, and adjusting treatment plans based on the patient’s evolving needs and responses to therapy. Mental health assessment forms can vary widely depending on the specific needs and conditions being assessed, but they typically include:

• Diagnostic Assessments: Structured tools or questionnaires that help diagnose specific mental health disorders, such as the DSM-5 criteria.
• Symptom Inventories: Surveys or checklists that measure the severity and frequency of symptoms, like the Beck Depression Inventory or the Generalized Anxiety Disorder 7-item (GAD-7) scale.
• Risk Assessments: Evaluations of the patient's risk for self-harm, suicide, or harm to others.
• Functional Assessments: Assessments of how the patient's mental health issues impact their daily functioning, including work, relationships, and self-care.

Using behavioral health assessment forms at large or small practices 

Behavioral health assessment forms are indispensable tools for both solo and group practices. These forms are often more comprehensive and detailed than intake forms, providing in-depth evaluations of a client’s mental health status through psychological tests, observations, and structured interviews. By utilizing these standardized forms, practices can ensure consistent care and accurate diagnosis, regardless of the size of the practice. They also allow for the systematic tracking of patient progress and the identification of high-risk individuals who may require more intensive intervention.

Choosing the right mental health forms is crucial for ensuring that the form meets the specific needs of the patient. Factors to consider in determining the right mental health assessment form include the type of therapy being provided (e.g., individual, couples, group) and the specific mental health conditions being addressed. Using the right form can enhance the efficiency of the intake process, improve the accuracy of the information collected, and ensure that all relevant details are captured. 

The role of mental health forms in developing treatment plans

Therapy intake forms and mental health assessment forms provide detailed information about a client's history, symptoms, and concerns. This data is largely relied upon by therapists as they develop personalized treatment plans. The information collected helps identify key areas to focus on and track the effectiveness of interventions over time. Regular mental health assessments, conducted at intervals recommended by the therapist, can help track progress and make necessary adjustments to the treatment plan, ensuring that the therapeutic approach remains effective and responsive to the client's evolving needs.

List of Mental Health Forms & Therapy Intake Forms Available

Below is a list of 40 of the most commonly used forms for mental health providers, most of which you would expect to find readily available in your chosen EHR and software management solution: 

• Patient Health Questionnaire 9 (PHQ-9)
• General Anxiety Disorder 7 (GAD-7)
• Mental Health Assessment and Treatment Plan
• Behavioral Health SOAP Note
• Behavioral Health Progress Note
• Psychiatric Evaluation Intake
• Psychiatric Follow-Up Note
• Biopsychosocial Assessment (Adult)
• Mental Status Evaluation
• Therapy Intake Questionnaire
• Therapy Progress Note
• Therapy Treatment Plan and Goals Note
• Therapy Discharge Summary
• Patient Safety Plan
• Couples Therapy Initial Intake Form
• Couples Therapy Treatment Plan and Progress Note
• Group Therapy Session Note
• Telehealth Therapy Informed Consent for a Minor
• Adolescent Intake Questionnaire
• Mood Disorder Questionnaire (MDQ)
• Suicide Risk Assessment
• Drug Abuse Screening Test (DAST-10)
• CAGE-AID Substance Abuse Screening Tool
• Alcohol Use Disorders Identification Test (AUDIT): Self-Report Version
• Beck Depression Inventory (BDI)
• Depression Anxiety Stress Scale-21 (DASS21)
• PTSD Checklist for DSM-5 (PCL-5)
• Brief-COPE Orientation to Problems Experience Inventory
• Dissociative Experience Scale (DES-II)
• Edinburgh Postnatal Depression Scale (EPDS)
• Neurotransmitter Assessment Form (NTAF)
• Obsessive-Compulsive Inventory Form (OCI-4)
• Perinatal Anxiety Screening Scale (PASS)
• Child Autism Spectrum Test (CAST)
• Pediatric Symptom Checklist (PSC-17)
• Pediatric Symptom Checklist (PSC-35)
• The CRAFFT Questionnaire (version 2.1)
• Adult ADHD Self Report Scale (ASRS v1.1) Symptom Checklist
• Adverse Childhood Experience (ACE) Questionnaire

Therapy forms and assessments available with Healthie’s EHR 

Practice management platforms like Healthie provide all the tools mental health providers need to manage their private practice and deliver patient care. Combining scheduling, charting, billing, and patient engagement into one platform, Healthie serves as an all-on-one solution for growing therapy practices. 

Healthie's suite of mental health forms – which includes all 40 mental health forms above – offers numerous advantages for behavioral health care providers. These tools save time by eliminating the need to create industry standard forms and ensure consistency in patient evaluations. 

Here are some benefits of using Healthie’s EHR for patient forms:

• Automatically send forms to patients for electronic completion.
• Use templated charting forms with auto-fill to save admin time.
• Easily share completed forms with care team members.
• Send post-session summaries or treatment plans using charting forms.
• Enable auto-scoring for GAD-7 and PHQ-9 assessment forms.
• Set up recurring assessment forms (e.g., monthly) for regular monitoring.
• Create custom forms with the intuitive form builder.

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