Online Intake

Form Templates

Easily send and receive your intake forms online. Send clients your online intake forms to fill out on their phone, tablet, or computer. Clients securely sign and submit completed intake forms. Track the progress of new patient intake forms, send automated reminders, and receive completed forms online.
HIPAA PolicyConsent to TreatmentPatient Registration

Template Library

Unlock efficiency and enhance patient care with our extensive template library for streamlined digital forms.
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General - Financial Responsibility Form
Dental
Medical
Mental Health
Optometry
Explains a patient’s agreement to pay for services and accept financial responsibility for uncovered charges.
General - Notice of Privacy Practices
Dental
Medical
Mental Health
Optometry
Law
Explains how patient health data is protected and outlines rights under HIPAA.
General - Consent to Treatment
Dental
Medical
Mental Health
Optometry
Confirms a patient’s informed, voluntary agreement to receive medical care.
General - Telehealth Consent
Medical
Mental Health
Optometry
Dental
Informs patients of their rights and risks before receiving care via video or phone.
General - Medical History Form
Medical
Mental Health
Efficiently collect and review patients' past medical information, aiding in comprehensive assessments, accurate diagnoses, and personalized treatment plans
General - Cancelation Policy
Medical
Dental
Mental Health
Optometry
Discover how a well-crafted cancellation policy creates better outcomes for healthcare providers and patients alike. Our comprehensive guide includes a ready-to-use template, essential policy components, and implementation strategies.
Consent for AI Scribe Use — Patient Informed Consent Form
Medical
Mental Health
Optometry
Dental
Digitize AI scribe consent with Zentake. HIPAA-compliant, e-signature ready, and state-law compliant. Collect patient consent for AI-assisted documentation before every visit. Start free.
Dental Medical and Health History Form — New Patient Clinical Record
Dental
Digitize your dental medical and health history form with Zentake. HIPAA-compliant, auto-routed, and EMR-ready. Collect complete patient histories before the appointment.
Dental Patient Information Form — New Patient Registration
Dental
Digitize your dental patient information form with Zentake. HIPAA-compliant, paperless, and EMR-ready. Collect contact, insurance, and demographic data before the first visit.
Chiropractic Intake Form — New Patient History & Assessment
Chiropractic
Digitize your chiropractic intake process with Zentake. HIPAA-compliant, auto-routed, and EMR-ready. Capture chief complaint, pain history, and health history online. Start free.
Dental Financial Responsibility Form — Patient Payment Policy Agreement
Dental
Digitize your dental financial responsibility form with Zentake. HIPAA-compliant, paperless, and e-signature ready. Collect payment agreements before the appointment.
General - Medical Records Release Authorization
Medical
Optometry
Dental
Mental Health
HIPAA-Compliant Template for Requesting Medical Records
Pediatrics - Refusal of Recommended Immunizations
Pediatrics
Documents a parent’s informed refusal of vaccines to reduce liability and support clear communication.
Biopsychosocial Assessment Form — Structured Mental Health Intake | Zentake
Mental Health
Digitize the biopsychosocial assessment form with Zentake. HIPAA-compliant, structured intake fields, and EMR-ready. Start your free trial today.
Counseling Intake Form — New Patient Mental Health Assessment
Mental Health
Digitize your counseling intake with Zentake. HIPAA-compliant, customizable, and EMR-ready. Streamline first sessions and reduce admin time.
Medical - Insurance Verification Form
Medical
Confirms patient insurance coverage and benefits to ensure accurate billing and reduce claim denials.
OB-GYN Patient History Form
Medical
Collects essential reproductive and medical history to guide OB-GYN care and support patient wellness.
Generalized Anxiety Disorder Assessment (GAD-7)
Mental Health
Medical
Screens for anxiety symptoms with a quick, validated 7-question assessment used in primary and mental health care.
Patient Health Questionnaire (PHQ-9)
Medical
Mental Health
Evaluate and track the severity of depressive symptoms in patients, enabling more accurate diagnoses and guiding personalized treatment.
ASRS-v1.1 Adult ADHD Screener — Self-Report Scale | Zentake
Mental Health
Digitize the ASRS-v1.1 with Zentake. HIPAA-compliant, auto-scored (Part A + 18-item total), and EMR-ready. Screen adults for ADHD in under 10 minutes. Start your free trial.
NICHQ Vanderbilt Assessment Scale
Pediatrics
Use these tools to evaluate ADHD and behavioral symptoms in children, gathering insights from parents and teachers for a well-rounded diagnosis.
Vaccine Consent
Medical
Provides informed consent for vaccinations, ensuring legal compliance and patient understanding.
DASS-Y Depression Anxiety Stress Scale Youth — Child & Adolescent Screening Tool
Mental Health
Pediatrics
Digitize the DASS-Y with Zentake. HIPAA-compliant, auto-scored for ages 7–18, and EMR-ready. Measure depression, anxiety, and stress in youth. Free trial.
DASS-21 Depression Anxiety Stress Scales — Digital Assessment Tool
Mental Health
Digitize the DASS-21 with Zentake. HIPAA-compliant, auto-scored across depression, anxiety, and stress subscales, and EMR-ready. Start your free trial.
PTSD Checklist for DSM-5 (PCL-5)
Mental Health
Records patient-reported PTSD symptoms securely to guide clinical decisions, track progress, and ensure compliant documentation.
SCARED Parent Form — Digital Anxiety Screening Tool
Mental Health
Pediatrics
Digitize the SCARED Parent Form with Zentake. HIPAA-compliant, auto-scored, and EMR-ready. Screen childhood anxiety in ages 8–18. Start your free trial.
Pittsburg Insomnia Rating Scale (PIRS-20)
Mental Health
Measures sleep quality and insomnia severity to support efficient, secure, and data-driven sleep assessments for clinical and research applications.
Perceived Stress Scale (PSS-10)
Mental Health
Measures perceived stress levels to support early identification, preventive care, and secure, data-driven mental health assessments.
Functional Analysis Screening Tool (FAST)
Mental Health
Identifies the functions of challenging behaviors to support data-driven treatment planning, behavioral interventions, and secure, collaborative clinical assessments.
Short Michigan Alcohol Screening Test (SMAST)
Medical
Screens adult alcohol use and related behaviors to support early detection, intervention planning, and secure, evidence-based clinical assessments.
C-SSRS Suicide Risk Assessment — Columbia Protocol Digital Tool
Mental Health
Digitize the Columbia-Suicide Severity Rating Scale (C-SSRS) with Zentake. HIPAA-compliant, auto-flagged risk alerts, and EMR-ready. Start your free trial.
Suicide Behaviors Questionnaire (SBQ-R)
Mental Health
Assesses suicidal thoughts and behaviors to support early detection, personalized intervention, and secure, evidence-based suicide risk management.
Michigan Alcohol Screener - Geriatric (MAST-G)
Medical
Mental Health
Screens alcohol use and related risks in older adults to support early detection, informed care planning, and secure, evidence-based clinical assessments.
CIWA-Ar Alcohol Withdrawal Scale — Digital Assessment Tool
Medical
Digitize the CIWA-Ar with Zentake. HIPAA-compliant, auto-scored, and EMR-ready for safer alcohol withdrawal monitoring. Start your free trial.
The Tobacco, Alcohol, Prescription Medications, and Other Substance Tool (TAPS I & II)
Medical
Screens for tobacco, alcohol, prescription, and other substance use to support early intervention and informed clinical decision-making.
Michigan Alcohol Screening Test (MAST)
Medical
Identifies alcohol use patterns and risks to guide early intervention, treatment planning, and evidence-based clinical care.
Self-Administered Alcoholic Screening Test (SAAST-R)
Medical
Screens for potential alcohol dependence to support early intervention, informed treatment planning, and improved patient outcomes.
CORE-OM Outcome Measure — 34-Item Therapy Progress Assessment
Mental Health
Digitize the CORE-OM with Zentake. HIPAA-compliant, auto-scored across 4 domains, and EMR-ready. Track therapy outcomes over time. Start your free trial.
CORE-10 Psychological Distress Measure — Digital Outcome Tool
Mental Health
Digitize the CORE-10 with Zentake. HIPAA-compliant, auto-scored, and EMR-ready for routine outcome monitoring in therapy. Start your free trial.
Wender Utah Rating Scale (WURS)
Mental Health
Screens adult ADHD symptoms based on childhood experiences to support accurate diagnosis and evidence-based treatment planning.
DBT-WCCL — Dialectical Behavior Therapy Ways of Coping Checklist
Mental Health
Digitize the DBT-WCCL with Zentake. HIPAA-compliant, auto-scored, and EMR-ready. Measure DBT skills use and dysfunctional coping. Start your free trial.
Hamilton Anxiety Rating Scale (HAM-A)
Mental Health
Measures anxiety severity to support accurate diagnosis, treatment planning, and clear clinical documentation.
Perinatal Anxiety Screening Scale (PASS)
Mental Health
Assesses perinatal anxiety to guide safe, early interventions for maternal mental health.
Zung Self-Rating Anxiety Scale (SAS)
Mental Health
Measures anxiety levels through a 20-item self-report questionnaire to support accurate screening, monitoring, and treatment planning.
Professional Quality of Life Scale (ProQOL)
Mental Health
Evaluates caregiver well-being and stress levels to guide supportive interventions and promote healthier workplace performance.
ACE Questionnaire — Adverse Childhood Experiences Screening Tool | Zentake
Mental Health
Digitize the ACE Questionnaire with Zentake. HIPAA-compliant, auto-scored 10-item childhood trauma screen. Track patient ACE scores over time. Start your free trial.
Epworth Sleepiness Scale (ESS) — Daytime Sleepiness Screening Tool
Medical
Mental Health
Digitize the Epworth Sleepiness Scale with Zentake. HIPAA-compliant, auto-scored, and EMR-ready. Screen for excessive daytime sleepiness in under 2 minutes. Start your free trial.
International Prostate Symptom Score (I-PSS)
Medical
Assesses urinary symptoms to support accurate prostate health evaluation and informed clinical decisions.
Medical Symptoms Questionnaire (MSQ)
Medical
Evaluates overall symptom patterns to help identify health imbalances and guide personalized treatment planning.
FSS Fatigue Severity Scale — 9-Item Fatigue Assessment Tool
Mental Health
Medical
Digitize the FSS with Zentake. HIPAA-compliant, auto-scored, and EMR-ready. Screen for clinically significant fatigue in MS, lupus, and chronic conditions. Start your free trial.
FADI Foot and Ankle Disability Index — Function & Pain Assessment
Physical Therapy
Digitize the FADI with Zentake. HIPAA-compliant, auto-scored, and EMR-ready. Assess foot and ankle function in chronic ankle instability and rehabilitation. Start your free trial.
Modified Checklist for Autism in Toddlers, Revised (M-CHAT-R)
Pediatrics
Collects key developmental insights from toddlers to guide early autism detection and personalized follow-up care.
Patient Satisfaction Survey
Medical
Collects patient feedback digitally to guide improvements in care quality, communication, and overall experience.
Lower Extremity Functional Scale (LEFS)
Physical Therapy
Collects patient-reported lower limb mobility data to guide personalized rehabilitation and track functional recovery.
Pelvic Floor Impact Questionnaire (PFIQ-7)
Medical
Physical Therapy
Collects patient-reported pelvic floor data to guide personalized care and track functional outcomes efficiently.
AD8 Dementia Screening Interview — Digital Cognitive Assessment | Zentake
Medical
Digitize the AD8 Dementia Screening Interview with Zentake. HIPAA-compliant, auto-scored, and EMR-ready. Detect early cognitive decline fast. Start free.
Patient Health Questionnaire – 2 (PHQ-2)
Mental Health
Quickly assess patients’ risk for depression using the PHQ-2, supporting timely clinical decisions, effective monitoring, and streamlined mental health screening.
ADAM Questionnaire — Low Testosterone Screening Tool | Zentake
Medical
Digitize the ADAM Questionnaire for androgen deficiency screening with Zentake. HIPAA-compliant, auto-scored, EMR-ready. Screen for low testosterone. Free trial.
DES-B Dissociation Scale — Brief Dissociative Experiences Assessment | Zentake
Mental Health
Medical
Digitize the DES-B with Zentake. HIPAA-compliant, auto-scored (raw total + average severity), and EMR-ready. Screen adults for dissociation in under 5 minutes. Start your free trial.
Advance Beneficiary Notice of Non-Coverage (ABN) — Medicare Financial Liability Form
Medical
Law
Digitize the ABN (CMS-R-131) with Zentake. HIPAA-compliant, e-signature ready, and EMR-integrated. Protect your practice and inform Medicare patients before services. Start your free trial.
ACE Questionnaire — Adverse Childhood Experiences Screening Tool | Zentake
Medical
Mental Health
Digitize the ACE Questionnaire with Zentake. HIPAA-compliant, auto-scored (0–10 ACE Score), and EMR-ready. Screen for childhood trauma in under 10 minutes. Start your free trial.
ACE-Adult Questionnaire — Adverse Childhood Experiences for Adults | Zentake
Mental Health
Medical
Digitize the ACE-Adult Questionnaire with Zentake. HIPAA-compliant, auto-scored childhood trauma screening for adult patients. EMR-ready. Start your free trial.
AMS Questionnaire — Aging Males' Symptoms Scale | Zentake
Medical
Digitize the AMS Questionnaire with Zentake. HIPAA-compliant, auto-scored 17-item aging male symptoms assessment. Track treatment outcomes. Start your free trial.
AUDIT-C Alcohol Screening — Hazardous Drinking Assessment Tool
Medical
Digitize the AUDIT-C with Zentake. HIPAA-compliant, auto-scored, and EMR-ready. Screen for hazardous drinking in under 1 minute. Start your free trial.
ASRM Mania Scale — Altman Self-Rating Mania Screening Tool
Mental Health
Digitize the Altman Self-Rating Mania Scale with Zentake. HIPAA-compliant, auto-scored, and EMR-ready. Screen for mania in under 2 minutes. Start your free trial.
AAI Appearance Anxiety Inventory — Body Dysmorphic Disorder Screening Tool
Mental Health
Digitize the Appearance Anxiety Inventory with Zentake. HIPAA-compliant, auto-scored, and EMR-ready. Screen for BDD-related anxiety in under 3 minutes. Start your free trial.
AVHRS Auditory Vocal Hallucination Rating Scale — Digital Voice Hearing Assessment
Mental Health
Digitize the AVHRS with Zentake. HIPAA-compliant, auto-scored auditory hallucination assessment for clinical monitoring. Start your free trial.
AQ Autism Spectrum Quotient — 50-Item Autistic Traits Self-Assessment | Zentake
Mental Health
Digitize the AQ-50 with Zentake. HIPAA-compliant, auto-scored autism traits screening for adults 16+. Five subscales, instant results. Start your free trial.
AQ-10 Adolescent Autism Screening — 10-Item Spectrum Quotient for Ages 12–15 | Zentake
Pediatrics
Mental Health
Digitize the AQ-10 Adolescent with Zentake. HIPAA-compliant, auto-scored 2-minute autism screening for ages 12–15. Start your free trial.
AQ-10 Child Autism Screening — 10-Item Parent-Report Screener for Ages 4–11 | Zentake
Mental Health
Medical
Digitize the AQ-10 Child autism screener with Zentake. HIPAA-compliant, auto-scored, parent-report tool for ages 4–11. Start your free trial.
AQ-10 Adult Autism Screening — 10-Item Spectrum Quotient Self-Assessment | Zentake
Mental Health
Digitize the AQ-10 Adult autism screener with Zentake. HIPAA-compliant, auto-scored, and EMR-ready. Screen autistic traits in 2–5 minutes. Start free.
ASSQ Autism Screening Questionnaire — 27-Item Parent/Teacher Rating Scale for Ages 6–17 | Zentake
Mental Health
Pediatrics
Medical
Digitize the ASSQ autism screener with Zentake. 27-item parent/teacher rating scale, auto-scored, HIPAA-compliant. Ages 6–17. Start free.
BASDAI Ankylosing Spondylitis Scale — Disease Activity Index
Medical
Physical Therapy
Digitize the BASDAI with Zentake. HIPAA-compliant, auto-scored, and EMR-ready. Measure AS disease activity in under 2 minutes. Start your free trial.
BDI-II Beck Depression Inventory — Depression Severity Screening
Mental Health
Medical
Digitize the BDI-II with Zentake. HIPAA-compliant, auto-scored, and EMR-ready. Screen depression severity in 5–10 minutes. Start your free trial.
Biopsychosocial Assessment — Comprehensive Clinical Intake Tool | Zentake
Medical
Pediatrics
Mental Health
Digitize the biopsychosocial assessment with Zentake. HIPAA-compliant, streamlined intake, and EMR-ready clinical documentation. Start your free trial.
Berg Balance Scale (BBS) — Fall Risk & Balance Assessment | Zentake
Medical
Pediatrics
Physical Therapy
Digitize the Berg Balance Scale with Zentake. HIPAA-compliant, auto-scored, and EMR-ready. Assess balance and fall risk in 15–20 minutes. Start your free trial.
BDRS Bipolar Depression Rating Scale — Clinician-Rated Depression Assessment | Zentake
Mental Health
Medical
Digitize the BDRS with Zentake. 20-item clinician-rated bipolar depression scale, auto-scored, HIPAA-compliant, EMR-ready. Start your free trial.
CARS-2 Questions for Parents: Childhood Autism Rating Scale Caregiver Form
Mental Health
Medical
Digitize the CARS-2 QPC with Zentake. HIPAA-compliant, EMR-ready caregiver intake for autism assessment. Gather structured parent input before clinical rating. Start free.
Bournemouth Questionnaire — Back Pain Outcome Measure
Medical
Chiropractic
Physical Therapy
Digitize the Back Bournemouth Questionnaire with Zentake. HIPAA-compliant, auto-scored, and EMR-ready. Track back pain outcomes across 7 dimensions. Start your free trial.
Adult Attachment Questionnaire (AAQ) — Attachment Style Assessment
Mental Health
Digitize the Adult Attachment Questionnaire with Zentake. HIPAA-compliant, auto-scored attachment style screening, EMR-ready. Start your free trial.
COWS Opiate Withdrawal Scale — Digital Assessment Tool
Medical
Digitize the COWS with Zentake. HIPAA-compliant, auto-scored, and EMR-ready for safer opioid withdrawal management. Start your free trial.
MSI-BPD Borderline Personality Disorder Screening — McLean Screening Instrument | Zentake
Mental Health
Digitize the MSI-BPD borderline personality screening with Zentake. 10-item validated screener, HIPAA-compliant, auto-scored, and EMR-ready. Start your free trial.
CUPIT Cannabis Screening — Cannabis Use Problems Identification Test | Zentake
Medical
Mental Health
Digitize the CUPIT cannabis screening with Zentake. HIPAA-compliant, auto-scored with 2 subscales, and EMR-ready. Screen for cannabis use disorder. Free trial.
CES-DC: Center for Epidemiological Studies Depression Scale for Children
Medical
Mental Health
Pediatrics
Digitize the CES-DC with Zentake. HIPAA-compliant, auto-scored depression screening for children ages 6-17. EMR-ready and trackable over time. Start your free trial.
ECR-R Attachment Scale — Experiences in Close Relationships Revised
Medical
Mental Health
Digitize the ECR-R with Zentake. HIPAA-compliant, auto-scored, and EMR-ready. Assess adult attachment anxiety and avoidance in under 10 minutes. Start your free trial.
Geriatric Depression Scale - 15
Medical
Mental Health
Assesses depressive symptoms in older adults to support early detection, guide mental health interventions, and improve patient care outcomes.
Informed Consent - GLP-1 Agonist (Semaglutide and Tirzepatide)
Medical
Assesses patient understanding of GLP-1 receptor agonist therapy to ensure informed decision-making, enhance treatment adherence, and support safe, effective care planning.
Informed Consent - Male Testosterone Pellet Insertion
Medical
Facilitates informed patient decisions by clearly outlining the procedure, benefits, and risks of male testosterone pellet therapy.
Liebowitz Social Anxiety Scale (LSAS)
Medical
Mental Health
Measures fear and avoidance in social situations to assess social anxiety severity and support personalized mental health care.
Life Events Checklist - LEC-5
Mental Health
Assesses exposure to potentially traumatic events to help identify risk factors for PTSD and guide personalized mental health care.
Menopause Rating Scale (MRS)
Medical
Mental Health
Assesses menopausal symptoms to identify severity, monitor their impact on quality of life, and guide personalized wellness and treatment planning.
Neck Index
Medical
Physical Therapy
Assesses neck function, mobility, and posture to help identify musculoskeletal issues and guide personalized care planning.
Revised Child Anxiety and Depression Scale - Child version (RCADS-Child)
Medical
Pediatrics
Mental Health
Assesses anxiety and depression symptoms in children to guide early intervention and support personalized mental health care planning.
Subjective Opiate Withdrawal Scale (SOWS)
Medical
Mental Health
Physical Therapy
Assesses patient-reported opioid withdrawal symptoms to help monitor treatment progress and guide personalized detoxification care.
Upper Extremity Function Scale (UEFS)
Medical
Physical Therapy
Assesses upper limb function to measure recovery progress and support targeted rehabilitation planning.
Quick DASH
Medical
Physical Therapy
Assesses upper extremity function to identify arm, shoulder, and hand limitations and guide personalized rehabilitation and treatment planning.
PCL-S - PTSD Checklist - Specific
Medical
Mental Health
Assesses trauma-related symptom severity tied to specific events to support accurate PTSD evaluation and informed, personalized care planning.
SF-12 Health Survey — Quality of Life Assessment Tool
Medical
Mental Health
Physical Therapy
Digitize the SF-12 with Zentake. HIPAA-compliant, auto-scored physical & mental health summary scores, EMR-ready. Start your free trial.
ABS Agitated Behavior Scale — TBI Agitation Assessment Tool
Medical
Mental Health
Digitize the Agitated Behavior Scale with Zentake. HIPAA-compliant, auto-scored, and EMR-ready. Assess TBI agitation digitally. Start your free trial.
ALSFRS-R ALS Functional Rating Scale — Disease Progression Assessment
Medical
Digitize the ALSFRS-R with Zentake. HIPAA-compliant, auto-scored, and EMR-ready. Track ALS functional decline over time. Start your free trial.

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