Initial Intake Screening Form

INTAKE FORM

Name
This field is for validation purposes and should be left unchanged.
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
- No
Are you currently experiencing thoughts of harming others?
- Yes
- No
Are you currently experiencing hallucinations, paranoia, or severe confusion?
- Yes
- No
Have you been discharged from a psychiatric hospital within the past 12 months?
- Yes
- No
Are you currently experiencing severe withdrawal from alcohol, benzodiazepines, or other substances?
- Yes
- No
Are you currently using illicit substances daily or unable to remain abstinent long enough to attend outpatient appointments?
- Yes
- No
Are you currently pregnant or believe you may be pregnant?
- Yes
- No
Are you able to safely participate in outpatient telehealth psychiatric care?
- Yes
- No
Name(Required)
Phone(Required)
Email(Required)

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Psychaitric Mental Health Care for Adults in Washington and Oregon

Phone: (253) 796-8967

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