Patient Intake Form

Personal Details

Medical History

Family & Background

Lifestyle & Goals

Welcome to The Mental Circle's comprehensive patient intake form.

This multi-step form helps us understand your complete picture and provide the best possible treatment. All information is confidential and protected under POPIA.

At minimum, we need your name, ID number, and medical aid details. All other fields are optional - feel free to leave them blank if you prefer to discuss in person.

* indicates required field

Step 1: Personal Details & Administrative Information

Basic Information

Title *

First Names (as on ID/Medical Aid) *

Preferred Name *

Surname *

ID Number *

Age

Email Address *

Phone Number *

Gender *

Marital Status *

Occupation *

Employer *

Residence (where and with whom) *

Medical Aid Details (if applicable)

Medical Aid

Plan

Medical Aid Number

Dependant Code

Person Responsible for Medical Aid Account

Same as above (I am responsible for the medical aid account)

Next of Kin (Emergency Contact)

Name *

Phone Number *

Relationship *

Step 2: Medical & Psychiatric History

Medical History

Chronic illnesses

Past serious illnesses, operations, or injuries (including head injuries)

Current medications (include dosages if known)

Supplements or vitamins

Psychiatric History

Past contact with mental health professionals

Previous mental health diagnoses

Previous psychiatric medications

Substance Use

Smoking

Alcohol use

Other substance use

Step 3: Family & Background History

Family History

Please describe immediate family members (parents, siblings, children) including their age, any medical/psychiatric illnesses, personality, and your relationship with them.

Family Members

Early Development & Education

Pregnancy, birth, and early childhood

School performance

School behaviour

Tertiary education (if applicable)

Work & Relationships

Work history

Significant relationships

Trauma (Optional)

You may skip this section if preferred. This will be discussed sensitively in person.

Have you experienced trauma?

Age when occurred (if applicable)

Step 4: Lifestyle & Goals

Personality & Self-Perception

How would you describe yourself? (1-2 sentences)

How would others describe you? (1-2 sentences)

Lifestyle

Hobbies and interests

Exercise routine

Typical diet

Sleep pattern

Dreams & Goals

What are your dreams for the future?

Goal for next month

Goal for next year

Step 1: Personal Details & Administrative Information

Basic Information

Medical Aid Details (if applicable)

Person Responsible for Medical Aid Account

Next of Kin (Emergency Contact)

Step 2: Medical & Psychiatric History

Medical History

Psychiatric History

Substance Use

Step 3: Family & Background History

Family History

Early Development & Education

Work & Relationships

Trauma (Optional)

Step 4: Lifestyle & Goals

Personality & Self-Perception

Lifestyle

Dreams & Goals

Agreement *