Use our readymade template to create this Google form. Customize it further using our form builder.
Create your intake form
- Use prebuilt template to create a HIPAA compliant online mental health intake form
- Collect patient, demography, emergency contact details, medical history
- Collect current mental health symptoms, substance use, suicide risk information
- Allow patients to upload their driver�s id, pharmacy prescriptions for medications
- Get signatures for consent for treatment, notice of privacy practices, use of PHI
Collect responses from your patients
| What are the problem(s) for which you are seeking help? | Feeling anxious |
| Current symptoms | Racing thoughts,Excessive worry,Anxiety attacks,Crying spells,Fatigue,Concentration/forgetfulness,Depressed mood |
| What are currently your main sources of stress? | Worried about health, feeling overwhelmed, don't have much or any control over the outcome of a situation. |
| What are your treatment goals? | Reduce stress |
| Are you currently having thoughts of harming yourself? | No |
| Are you currently having thoughts of harming others? | No |
| Have you ever seen a psychiatrist before? | No |
| Has anyone in your family been diagnosed with or treated for: | Depression,Anxiety |
| Do you think you may have a problem with alcohol or drug use? | No |
| Have you ever been treated for alcohol or drug use or abuse? | No |
| Have you tried any of the following? | Tranquilizer/sleeping pills,Alcohol |
| How you ever smoked cigarettes? | No |
| Do you smoke currently? | No |
| Date Signed | 2023-08-08 |
| Date Signed | 2023-08-08 |
| Date Signed | 2023-08-08 |
- Pre-populate patient details from your booking system to reduce errors
- Send an email invitation with a secure link for patients to complete their intake
- Allow patients to save their progress and complete their form at a later time
- Set up an email template and send invitation emails to multiple patients with ease
- Send an email to the patients with a copy of their response when they submit the form
Track patient responses in Google Sheets
- Export patient responses to Google Sheets for easy record-keeping
- Create a custom workflow and manage your patient intake efficiently
- Use pre-built reports to easily keep track of patient progress over time
- Receive a copy of the response by email when a patient submits the intake form
- Use data in Google Sheets to integrate with EHR systems for seamless data transfer
HIPAA compliance
| What are the problem(s) for which you are seeking help?: | Feeling anxious |
| Current symptoms: | Racing thoughts, Excessive worry, Anxiety attacks, Crying spells, Fatigue, Concentration/forgetfulness, Depressed mood |
| What are currently your main sources of stress?: | Worried about health, feeling overwhelmed, don't have much or any control over the outcome of a situation. |
| What are your treatment goals? : | Reduce stress |
| Are you currently having thoughts of harming yourself?: | No |
| Are you currently having thoughts of harming others?: | No |
| Have you ever seen a psychiatrist before?: | No |
| Has anyone in your family been diagnosed with or treated for:: | Depression, Anxiety |
| Do you think you may have a problem with alcohol or drug use? : | No |
| Have you ever been treated for alcohol or drug use or abuse?: | No |
| Have you tried any of the following?: | Tranquilizer/sleeping pills, Alcohol |
| How you ever smoked cigarettes?: | No |
| Do you smoke currently?: | No |
| Date Signed: | 8/8/2023 |
| Date Signed: | 8/8/2023 |
| Date Signed: | 8/8/2023 |
- Create a HIPAA compliant intake form to safely collect, store and access patient responses
- Mark fields as Protected Health Information to secure sensitive data and limit access to PHI
- Mask PHI fields when exporting form responses to Google Sheets and sending them on email
- Pre-populate patient details in intake forms by creating secure prefill links without exposing PHI
- Limit access to patient data only for authorized personnel and minimize risk of data breaches
These reviews are reproduced without modification from Google Workspace Marketplace.
July 23, 2023
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October 31, 2023
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February 16, 2024
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July 12, 2023
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November 27, 2023
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July 10, 2023
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