The Mental Health Support Form Template by WPForms is a great tool for health practitioners, psychologists, and therapists who are looking for a simple way to gather referrals of mental health support for those who require it.
How Does the Mental Health Support Form Template Work?
The Mental Health Support Form Template requires the WPForms Pro License and the Signature Addon to collect information about the referrer and the patient and acquire appropriate consent. Here’s a brief description of the fields included:
- Referrer Information:
- Name: Captures the name of the person referring the patient.
- Phone: Contact number for the referrer.
- Email: Email address to send further correspondence.
- Relationship to Individual: Describes the referrer’s relationship to the patient.
- Individual Information:
- Name: Full name of the individual seeking support.
- Gender Identity: The patient’s gender identity for respectful communication.
- Preferred Pronouns: Pronouns the patient prefers to use.
- Date of Birth: Helps verify the age and provide age-appropriate support.
- Phone: Direct contact number for the patient.
- Email: Email address for sending appointments and important updates.
- Referral Reason & Details:
- Brief Description: A short description of the reason for seeking help.
- Mental Health History: An overview of any previous mental health issues.
- Diagnoses: Any existing mental health diagnoses.
- Current/Past Treatments: Details of treatments undertaken previously or currently.
- Medications Used: Information on any medications the patient is using.
- Preferred Provider: If the patient has a preference for a specific healthcare provider.
- Appointment Date/Time: Preferred dates and times for appointments.
- Comments/Instructions: Space for any additional comments or specific instructions.
- Referrer’s Signature:
- Consent: Ensures the referrer consents to the processing of their information.
- Signature and Date: For the patient or referrer to formally sign off.
Sign up with WPForms today and access the Mental Health Support Form Template. It is perfect for therapists, counselors, and mental health clinics who want to make client intake and management simple and efficient.
