Use our readymade template to create this Google form. Customize it further using our form builder.
Create your intake form
- Use prebuilt template to create a HIPAA compliant online mental health intake form
- Collect patient, demography, emergency contact details, medical history
- Collect current mental health symptoms, substance use, suicide risk information
- Allow patients to upload their driver�s id, pharmacy prescriptions for medications
- Get signatures for consent for treatment, notice of privacy practices, use of PHI
Collect responses from your patients
| What are the problem(s) for which you are seeking help? | Feeling anxious |
| Current symptoms | Racing thoughts,Excessive worry,Anxiety attacks,Crying spells,Fatigue,Concentration/forgetfulness,Depressed mood |
| What are currently your main sources of stress? | Worried about health, feeling overwhelmed, don't have much or any control over the outcome of a situation. |
| What are your treatment goals? | Reduce stress |
| Are you currently having thoughts of harming yourself? | No |
| Are you currently having thoughts of harming others? | No |
| Have you ever seen a psychiatrist before? | No |
| Has anyone in your family been diagnosed with or treated for: | Depression,Anxiety |
| Do you think you may have a problem with alcohol or drug use? | No |
| Have you ever been treated for alcohol or drug use or abuse? | No |
| Have you tried any of the following? | Tranquilizer/sleeping pills,Alcohol |
| How you ever smoked cigarettes? | No |
| Do you smoke currently? | No |
| Date Signed | 2023-08-08 |
| Date Signed | 2023-08-08 |
| Date Signed | 2023-08-08 |
- Pre-populate patient details from your booking system to reduce errors
- Send an email invitation with a secure link for patients to complete their intake
- Allow patients to save their progress and complete their form at a later time
- Set up an email template and send invitation emails to multiple patients with ease
- Send an email to the patients with a copy of their response when they submit the form
Track patient responses in Google Sheets
- Export patient responses to Google Sheets for easy record-keeping
- Create a custom workflow and manage your patient intake efficiently
- Use pre-built reports to easily keep track of patient progress over time
- Receive a copy of the response by email when a patient submits the intake form
- Use data in Google Sheets to integrate with EHR systems for seamless data transfer
HIPAA compliance
| What are the problem(s) for which you are seeking help?: | Feeling anxious |
| Current symptoms: | Racing thoughts, Excessive worry, Anxiety attacks, Crying spells, Fatigue, Concentration/forgetfulness, Depressed mood |
| What are currently your main sources of stress?: | Worried about health, feeling overwhelmed, don't have much or any control over the outcome of a situation. |
| What are your treatment goals? : | Reduce stress |
| Are you currently having thoughts of harming yourself?: | No |
| Are you currently having thoughts of harming others?: | No |
| Have you ever seen a psychiatrist before?: | No |
| Has anyone in your family been diagnosed with or treated for:: | Depression, Anxiety |
| Do you think you may have a problem with alcohol or drug use? : | No |
| Have you ever been treated for alcohol or drug use or abuse?: | No |
| Have you tried any of the following?: | Tranquilizer/sleeping pills, Alcohol |
| How you ever smoked cigarettes?: | No |
| Do you smoke currently?: | No |
| Date Signed: | 8/8/2023 |
| Date Signed: | 8/8/2023 |
| Date Signed: | 8/8/2023 |
- Create a HIPAA compliant intake form to safely collect, store and access patient responses
- Mark fields as Protected Health Information to secure sensitive data and limit access to PHI
- Mask PHI fields when exporting form responses to Google Sheets and sending them on email
- Pre-populate patient details in intake forms by creating secure prefill links without exposing PHI
- Limit access to patient data only for authorized personnel and minimize risk of data breaches
These reviews are reproduced without modification from Google Workspace Marketplace.
July 27, 2023
I am 100% a fan of this company. We use HIPAA compliant Google Forms and needed a way to collect signatures, the industry standard company is TOO expensive. I started using FormEsign and it worked perfectly. It lacked the ability to provide a pdf copy of the form after signature. This company worked with me help their product evolve into something that could benefit all future clients AND the end user. The team was polite, professional, kind, enthusiastic, and willing to make a change. This earned my loyalty. I will sing their praises. Good work, and thank you!
— Royal Bush
July 23, 2023
I am not tech savvy. I chose formesign to help create registration links for clients. Vipid has been great in assisting me. He goes above and beyond. My company now has moved from the stone age to modern age through the ability to use this feature. Of the many features I am impressed with, the ability to update a form without needing to regenerate a link is amazing. I often make mistakes and that ability allows me to fix mistakes without needing to change everything. Thank you!!!
— Sol Evans
February 16, 2024
Does not work
— Myles Sicuro
October 31, 2023
We needed a way to create forms with e-signatures and this app made it very easy. Support is also very quick and always helpful. Cannot recommend enough!
— Chris Henesy
July 12, 2023
It very friendly to used. I love it. For my case multiple signature needed. it's supporting
— Senthil Kumar
November 27, 2023
Yeah this is good for all
— luqman khan
July 10, 2023
We were looking for a way to have a signature option in our form. Formesign addon allowed us to collect signatures for the acknowledgment and consent forms. It was simple and easy to setup. Very useful addon for google forms.
— Joan S