Mental Health Screening template
An intake and triage form for a mental health service — not a diagnostic instrument. It asks what kind of support the person is looking for, what has been present in the last few weeks, how much it is affecting daily life, whether they have spoken to anyone before, and how soon they want a call. Nothing is scored, and the form says so in its own welcome text.
11 questions · works on the free plan (500 responses/month) · fully customizable
- 1 built-in logic rule
What’s inside
The questions this template ships with — rename, reorder, or delete any of them in the builder.
When to use this template
- A counseling service triaging new inquiries so the most urgent requests get called first rather than in submission order
- A group practice deciding whether an inquiry goes to a therapist or a prescriber, using the kind-of-support question
- A student wellbeing team taking self-referrals outside office hours with a clear crisis notice at the top
- An employer's mental health benefit collecting first contact before matching the employee with a provider
Tips to get more from it
- The second field is a display-only statement pointing anyone in immediate danger to emergency services and a crisis line, and stating that the form is only reviewed in office hours. Replace the generic wording with your local crisis numbers before publishing — this is the single most important edit on the form
- There is no quiz scoring on this template, and that is deliberate. The symptom checklist is context for a clinician, not a total; adding scores would turn an intake form into something it is not qualified to be
- The "how soon would you like to hear from us" question is the triage field. Sort your responses by it and work the list top-down
- The prior-support branch only asks who the person is working with when they say they are seeing someone — first-time contacts skip it
Questions people ask
Is this a diagnostic screening tool like PHQ-9 or GAD-7?
No. It is an intake and triage form. It collects context for a clinician to review and produces no score, no cutoff, and no result — validated instruments are administered by clinicians, not by a web form.
How does the form handle someone in crisis?
A statement near the start says the form is reviewed only in office hours and directs anyone in immediate danger to emergency services or a crisis line. Edit it to your local numbers, because the generic version helps nobody.
Can I use this for a clinical mental health service?
For scheduling and first contact, yes. But Zunoform does not offer a HIPAA Business Associate Agreement and has no SOC 2 report or SSO, so if your service handles protected health information under HIPAA, use a vendor that will sign a BAA for the clinical record and keep this to intake.
Do people have to answer everything?
Contact details, the kind of support wanted, prior-support history, and preferred response time are required; the symptom checklist, impact rating, and free-text box are optional, and the welcome text tells people to share only what they want to.
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