Mental Health Evaluation Form - Minnesota
Mental Health Clinic
Intake Assessment
Welcome to the Mental Health Clinic at Boynton Health Service. Before your first appointment, we’d like to
know some things about you and your concerns. This will assist us in helping you find what you are looking for.
What kind of services are you seeking?
____Individual cou nseling ____Medication evaluation/treatment ____Couple s counseling ___ _ Medical social work
____Group counseling ____Brief problem solving ____Required letter/documentation ____Alcohol/Drug assessment
Please describe the primary issue for your visit. You may use the descriptions on the back of this form to
assist you with your description. ___________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
There are some services that we are presently unable to offer or offer on a limited basis.
• ADD\ADHD: In order to be considered for ADD or ADHD medication treatment, you must provide us with copy
of your comprehensive ADD or ADHD evaluation for review prior to scheduling your first medication
appointment in the Mental Health Clinic. The Medical Social Worker can provide you with resources if you
require a n evaluation-- 612-624-8182.
• Eating Disorders: We provide an Eating Disorder Therapy program in coordination with medical and nutrition
services. We do not offer intensive Eating Disorder Treatment (including treatment for anorexia). Contact the
Medical Social Worker for resources– 612-624-8182.
• Long Term Therapy: The Mental Health Clinic utilizes a short-term model of psychotherapy. This means that
we are able to offer eleven individual or couples therapy visits within the period of one year. The Medical Social
Worker can p rovide you with resources– 612-624-8182.
• Legal Assessments: We are unable to provide legal assessments, with the exception of chemical health
assessm ents. The Medical Social Worker can provide you with re sources– 612-624-8182.
Psychiatric Hospitalizations/Past Treatment:
Mental Health Professiona l/Clinic: Situation/condition treated: Dates seen:
______________________________________ ________________________________ _________ _____
______________________________________ ________________________________ _________ _____
What medications, if any, are you currently taking or considering resuming?
__________________________________________________________________________________
The mental health professional that you will see at your first appointment will review the information that
you have provided. It is possible that they will want to talk to you by phone before you come in for the first
appointment. At what phone number may we reach leave a confidential message?
(____) ____ - ________
Age_____ Date of Birth_____________ Sex____ Email Address________________________
Mo/Day/Year
Freshman____Sophomore____Junior____Senior____Graduate____Professional____
Major area of study:________________________ Referred by_________________________________
If you are feeling acutely suicidal you must notify the Mental Health Clinic front desk so
they can arrange for you to speak with an Urgent Counselor.
Signature_______________________________ Date___________________
A reproduction of this form is as valid as the original
Label
Name:___________________________
MRN #:__________________________
Student ID #:______________________
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