Intake Screening Form | Axis Mental Health

Initial Intake Screening Form

Pre-Registration Screening — Not a Medical Evaluation

This brief screening helps determine whether Axis Mental Health telehealth services are appropriate at this time. This form does not collect medical records or personal health information. If you appear appropriate for outpatient telepsychiatry, you will be directed to register in our secure patient portal.

Are you currently experiencing thoughts of harming yourself or ending your life?

Yes

Are you currently experiencing thoughts of harming others?

Yes

Are you currently experiencing hallucinations, paranoia, or severe confusion?

Examples: hearing voices, seeing things others cannot see, feeling someone is trying to harm you.

Yes

Have you been discharged from a psychiatric hospital within the past 12 months?

Yes

Are you currently experiencing severe withdrawal from alcohol, benzodiazepines, or other substances?

Examples: shaking, seizures, severe nausea/vomiting, confusion.

Yes

Are you currently using illicit substances daily or unable to remain abstinent long enough to attend outpatient appointments?

Yes

Are you currently pregnant or believe you may be pregnant?

Yes

Not Applicable

Are you able to safely participate in outpatient telehealth psychiatric care?

Yes

Unsure