As a mental health clinician, 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 client 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 clinician 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. 

Types of mental health forms for your practices

Mental health practitioners use various forms to document client information and track progress. These forms can be categorized into 5 buckets: Intake, Charting, Assessment, Symptom Inventories/Screening, and Treatment Plan Forms. 

Below we go through the purposes of each of these 5 categories of forms and list 40 of the most commonly used forms for mental health clinicians, most of which you would expect to find readily available in your chosen EHR and software management solution. 

Intake Forms

When a client joins your practice, you will likely begin this relationship with an intake package that includes key forms essential for the healthy operations and compliance of your mental health practice, as well as forms necessary to begin a therapeutic relationship. 

Key forms essential for the daily operations of your mental health practice are standardized for all clients, and are not clinical in nature. These forms grant the clinician necessary permissions and confirm that clients are in agreement with your practice policies to ensure accurate expectations,smooth operations, and compliant protocols.

Practice Management Intake Forms

• Consent for Services and Fee Agreement Form
• Release of Information (HIPAA) Form
• Cancellation Policy Form
• No-Show Policy Form
• Auto-Payment Agreement Form
• Consent to use Electronic Communication

Intake forms are completed at the beginning of the therapeutic relationship and are used to ensure that clinicians have all the necessary information to prepare for the initial session. These forms are clinical in nature and cater to specific client needs and practice specialities, giving a thorough understanding of the client’s background and current situation. They generally gather demographic information, medical history, psychosocial history, and reasons for seeking treatment. 

It’s important to note that some intake forms aren’t just best practice, but legally required. For example, the Consent for Services and Fee Agreement Form details the practice’s fees in order to be compliant with the federal No Surprises Act (2022). Additionally, the Release of Information (HIPAA) Form, also known as the Notice of Privacy Practices, is a federally required mental health intake form that explains the use and disclosure of PHI. It is important to research what forms are legally required for your modality and state. 

Therapeutic Relationship Intake Forms

• Psychiatric Evaluation Intake
• Biopsychosocial Assessment (Adult)
• Therapy Intake Questionnaire
• Couples Therapy Initial Intake Form
• Telehealth Therapy Informed Consent for a Minor
• Adolescent Intake Questionnaire

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

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

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Charting Forms

Charting forms are essential tools for documenting client interactions and maintaining an organized record of the therapeutic process. These forms help mental health clinicians capture session details, including observations, progress, and changes in the client’s condition over time. They ensure continuity of care, especially when multiple clinicians or team members are involved in a client’s treatment. 

With standardized charting forms, mental health clinicians can streamline their note-taking processes, ensuring that all critical information is documented in real time. These forms create a reliable and compliant framework for clinicians to track therapeutic milestones and client outcomes, as well as be in compliance with state and federal laws. 

Charting Forms

• Couples Therapy Treatment Plan and Progress Note
• Therapy Discharge Summary
• Group Therapy Session Note
• Behavioral Health SOAP Note
• Behavioral Health Progress Note
• Psychiatric Follow-Up Note
• Therapy Progress Note

Assessment Forms

Assessment forms play a pivotal role in understanding a client’s mental health status. These forms are designed to gather detailed information about symptoms, behaviors, and psychological states to support accurate diagnoses and guide treatment plans. They often include structured questionnaires, checklists, or scales that assess specific mental health conditions or risk factors. 

By using standardized assessment forms, mental health providers can ensure consistency and reliability in evaluations. While there is not a federal law mandating the use of specific assessment forms, mental health providers have an ethical obligation as these tools are invaluable for identifying underlying issues, monitoring changes over time, and tailoring interventions to a patient's unique needs. 

Assessment Forms

• Mental Status Evaluation
• Mood Disorder Questionnaire (MDQ)
• Suicide Risk Assessment

Symptom Inventories & Screening Forms

Symptom inventories and screening forms are critical for detecting and measuring the severity of specific mental health issues. While these forms are not legally mandated, they are considered standard practice as they provide a snapshot of a client’s symptoms, offering valuable insights that help clinicians determine an appropriate course of action. Screening forms are useful during both the intake process and ongoing care to monitor progress or identify emerging concerns. 

Using these tools allows therapists to track symptom changes over time and adjust treatment plans accordingly. Many screening forms include auto-scoring features to simplify the analysis and facilitate faster, evidence-based decision-making. 

Symptom Inventories & Screening Forms

• Patient Health Questionnaire 9 (PHQ-9)
• General Anxiety Disorder 7 (GAD-7)
• 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)
• 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
• Neurotransmitter Assessment Form (NTAF)

Treatment Plans

Treatment plans serve as blueprints for a client’s therapeutic journey. These forms help clinicians outline goals, strategies, and timelines for addressing a client’s unique needs. They also provide a structure for tracking progress and ensuring accountability for both the therapist and the client. While many clinicians consider treatment plans to be best practice, the legal requirements for writing treatment plans is state-to-state. Additionally, some insurance providers - particularly Medicaid - require treatment plans for reimbursement. 

A well-crafted treatment plan includes measurable goals, defined interventions, and specific timelines for achieving outcomes. These forms enable therapists to maintain a collaborative approach, involving clients in their care and making adjustments as needed. 

Treatment Plans

• Mental Health Assessment and Treatment Plan
• Therapy Treatment Plan and Goals Note
• Patient Safety Plan

Remember, there’s no need to recreate these forms yourself. EHRs intentionally built for mental health clinicians, such as Healthie, provide a suite of forms readily available for clinicians. 

Using behavioral health assessments at large or small practices

Behavioral health assessments 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 in a meticulous manner. They also allow for the systematic tracking of client 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 specific needs of the client are being met. 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 client 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.

Therapy forms and assessments available with Healthie’s EHR 

Practice management platforms like Healthie provide all the tools mental health clinicians need to manage their private practice and deliver exceptional client care. Combining scheduling, charting, billing, and client 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 clinicians. These tools save time by eliminating the need to create industry standard forms and ensure consistency in client evaluations. 

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

• Automatically send forms to clients 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.

Healthie’s EHR, practice management, and client engagement platform can streamline the onboarding and management of mental health private practices, support best practices, and contribute to optimal outcomes for clients.

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