Better Me

Confidential patient intake

Welcome

This form helps your doctor understand you before your first session. It takes about 5–8 minutes.

There are no right or wrong answers — your responses help make your first session as useful as possible.

Your responses are confidential and shared only with your doctor and clinical team.

About you

A few basic details to start.

Your name

Your age

Gender

Male

Female

Non-binary

Prefer not to say

City / location (optional)

How did you hear about this practice? (optional)

Have you seen a psychiatrist before?

Yes

No — first time

What brings you here?

In your own words — no need to be formal.

What is the main thing you'd like help with?

What prompted you to seek help now? (optional)

Areas of difficulty

Select everything that has been affecting you — even if it feels minor. This helps your doctor make sure nothing gets missed.

How you've been feeling

Think about the past month as a whole.

Overall distress level5

No distressSevere distress

For each area below, pick the description that best fits the past month.

Day-to-day functioning

Sleep

Tell us more about your sleep, if it has been an issue.

Which of these describe your sleep? (select all that apply)

Important to share

These questions help your doctor be fully prepared. Your answers are confidential.

These questions can feel personal. Honest answers — even partial ones — help your doctor support you better from your very first session.

Have you ever had thoughts of harming yourself or ending your life?

Yes — I'm having these thoughts currently

In the past, but not currently

No, never

Prefer not to say

Do you use alcohol, tobacco, cannabis, or any other substances?

Yes, regularly

Occasionally or socially

No

Your history

Help your doctor understand what you've been through and what you're currently taking.

Have you received psychiatric or psychological treatment before?

Yes

No

Have you ever been admitted to hospital for mental health reasons?

Yes

No

Medical conditions (write 'none' if none)

Current medications (all — psychiatric and physical)

Your life

A little context about your day-to-day situation.

Who do you currently live with? (select all that apply)

Family history of mental health concerns (optional)

Yes

No

Not sure

Any details? (optional)

Your goals

Help your doctor understand what you're hoping for.

What do you hope to get from this consultation?

Is there anything you're hesitant or worried about sharing today? (optional)

Anything else you'd like your doctor to know? (optional)

Review and submit

Please review your summary below, then submit to send it securely to the practice.

Your response will be emailed securely to the practice team.

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Your information has been sent to your clinical team.

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