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Forensic Mental Hospital Intake Form

The Forensic Mental Hospital Intake Form is a document that is used to collect information about an individual who is seeking admission to a mental health facility. The form includes questions about the individual's personal information, medical history, and mental health history. The information collected on the form is used to determine whether the individual is eligible for admission to the mental health facility.

Time to complete

3 minutes

Eligibility

To be eligible to fill out the Forensic Mental Hospital Intake Form, an individual must be seeking admission to a mental health facility.

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Questions for Forensic Mental Hospital Intake Form

1.

What is your name?

The answer should be a text input.
2.

What is your date of birth?

The answer should be a date input.
3.

What is your Social Security Number?

The answer should be a text input.
4.

What is your current address?

The answer should be a text input.
5.

What is your phone number?

The answer should be a phone number.
6.

What is your email address?

The answer should be an email input.
7.

What is your employment status?

The answer should be a text input.
8.

What is your highest level of education?

The answer should be a text input.
9.

What is your criminal history?

The answer should be a text input.
10.

Have you ever been diagnosed with a mental illness?

The answer should be a single choice:
  1. Yes
  2. No
11.

Do you have a history of substance abuse?

The answer should be a single choice:
  1. Yes
  2. No
12.

Do you have a history of self-harm?

The answer should be a single choice:
  1. Yes
  2. No
13.

Do you have a history of suicide attempts?

The answer should be a single choice:
  1. Yes
  2. No
14.

Do you have a history of violence?

The answer should be a single choice:
  1. Yes
  2. No
15.

What are the current symptoms that you are experiencing?

The answer should be a text input.
16.

What is your current level of functioning?

The answer should be a text input.
17.

What is your current mental state?

The answer should be a text input.
18.

What is your current level of insight?

The answer should be a text input.
19.

What is your current level of judgment?

The answer should be a text input.
20.

What is your current level of impulse control?

The answer should be a text input.
21.

What are your current living arrangements?

The answer should be a text input.
22.

Do you have any current support system in place?

The answer should be a single choice:
  1. Yes
  2. No
  3. Unsure
23.

What are your current treatment goals?

The answer should be a text input.

Similar Ideas

  • Psychiatric Evaluation Form
  • Mental Health Evaluation Form
  • Mental Status Examination Form
  • Psychosocial Evaluation Form

Here are some FAQs and additional information
on Forensic Mental Hospital Intake Form

What is the purpose of the Forensic Mental Hospital Intake Form?

The Forensic Mental Hospital Intake Form is used to gather information about an individual who has been accused of or convicted of a crime and who is seeking treatment at a mental health facility. The form helps to assess the individual's mental health status and to determine whether they are a danger to themselves or others.

What information is gathered on the Forensic Mental Hospital Intake Form?

The form gathers information about the individual's criminal history, mental health history, and current mental health symptoms. The form also assesses the individual's risk for violence and their need for treatment.

How is the information on the Forensic Mental Hospital Intake Form used?

The information on the Forensic Mental Hospital Intake Form is used to assess the individual's mental health and to determine whether they are a danger to themselves or others. The information is also used to determine the individual's need for treatment.

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