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
Medical
Mental Health
Optometry
Dental
Informs patients of their rights and risks before receiving care via video or phone.
Dental - Medical and Dental Health History Form
Dental
Captures essential medical and dental history to ensure safe, personalized, and informed dental
Dental - Patient Information Form
Dental
Collects essential personal, medical, and dental history to support safe and efficient dental care.
Chiropractic - Intake Form
Chiropractic
Collects key health details and consent before chiropractic care to guide safe, personalized treatment.
Dental - Financial Responsibility Form
Dental
Outlines a patient’s payment obligations to reduce billing disputes and ensure financial transparency.
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
Mental Health
Comprehensive Patient Evaluation Tool for Mental Health and Integrated Care Settings
Counseling Intake Form
Mental Health
Collects key personal and psychological history to guide safe, personalized therapy from the first session.
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.
Adult ADHD Self-Report Scale (ASRS-v1.1) Symptom Checklist
Mental Health
18-item tool for adults 18+ to screen for ADHD symptoms and aid in diagnosis, best used with a clinical interview.
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.
Depression Anxiety Stress Scale - Youth (DASS-Y)
Mental Health
Pediatrics
Assesses depression, anxiety, and stress in youth to support early detection, intervention planning, and secure, evidence-based mental health care.
Depression Anxiety Stress Scale (DASS-21)
Mental Health
Assesses depression, anxiety, and stress symptoms to support early detection, treatment planning, and secure, data-driven mental health care.
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.
Screen for Child Anxiety Related Disorders - Parent (SCARED)
Mental Health
Pediatrics
Screen and measure childhood anxiety efficiently with Zentake’s HIPAA-secure digital SCARED Parent Form — designed to deliver accurate, automated results while maintaining privacy and improving workflow for clinicians, parents, and educators.
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.
Columbia-Suicide Severity Rating Scale (C-SSRS)
Mental Health
Evaluates suicidal thoughts and behaviors to support early detection, informed intervention, and secure, evidence-based suicide risk management.
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.
Clinical Institute Withdrawal Assessment of Alcohol Scale, Revised (CIWA-Ar)
Medical
Assesses alcohol withdrawal severity to guide safe detoxification, medication management, and evidence-based clinical care.
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.
Critical Outcomes in Routine Evaluation (CORE OM)
Mental Health
Screens for potential alcohol dependence to support early intervention, informed treatment planning, and improved patient outcomes.
Clinical Outcomes in Routine Evaluation 10 (CORE-10)
Mental Health
Measures psychological distress and well-being to help clinicians track therapeutic progress and improve evidence-based mental health care.
Wender Utah Rating Scale (WURS)
Mental Health
Screens adult ADHD symptoms based on childhood experiences to support accurate diagnosis and evidence-based treatment planning.
Dialectical Behavior Therapy Ways of Coping Checklist (DBT-WCCL)
Mental Health
Evaluates coping strategies and emotion regulation to strengthen treatment planning and support effective DBT-based client care.
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.
Adverse Childhood Experience Questionnaire (ACE)
Mental Health
Assess and identify the impact of adverse childhood experiences to support trauma-informed care, improve patient understanding, and guide personalized behavioral health treatment.
Epworth Sleepiness Scale (ESS)
Medical
Mental Health
Assesses daytime sleepiness to help identify sleep disorders and support informed clinical decisions.
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.
Fatigue Severity Scale (FSS)
Mental Health
Medical
Measures the impact of fatigue on daily functioning to support accurate assessment and personalized care planning.
Foot and Ankle Disability Index (FADI)
Physical Therapy
Evaluates foot and ankle function to support accurate recovery tracking and personalized rehabilitation planning.
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
Medical
Collects caregiver-reported cognitive changes to guide early dementia detection and personalized follow-up care.
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 about symptoms of low testosterone
Medical
Screens for symptoms of low testosterone to support early detection and treatment decisions.
Adult Brief Dissociative Experiences Scale–Modified (DES-B)
Mental Health
Medical
Digitally assess dissociative symptoms to support trauma-informed care, early intervention, and structured mental health evaluations.
Advance Beneficiary Notice of Non-coverage (ABN)
Medical
Law
Digitally notify Medicare patients of potential non-covered services to support informed consent, billing transparency, and regulatory compliance.
Adverse Childhood Events Scale (ACES)
Medical
Mental Health
Screen for childhood trauma exposure to support early intervention, risk stratification, and trauma-informed care.
Adverse Childhood Experience Questionnaire for Adults (ACE-Adult)
Mental Health
Medical
Screen for early-life trauma exposure to support trauma-informed care, risk assessment, and personalized treatment planning.
Aging Male Symptoms Scale (AMS) Questionnaire
Medical
Digitally assess symptoms of testosterone decline in aging men, supporting early detection, personalized care, and efficient hormone therapy monitoring.
Alcohol Use Disorders Identification Test (AUDIT-C)
Medical
Digitally screen for symptoms of low testosterone, supporting early detection, informed clinical decisions, and streamlined hormonal care.
Altman Self-Rating Mania Scale (ASRM)
Mental Health
Assesses manic symptoms in bipolar disorder to support accurate monitoring, early detection, and streamlined digital documentation through Zentake’s secure platform.
Appearance Anxiety Inventory (AAI)
Mental Health
Measures appearance-related anxiety and behaviors to support accurate screening, treatment tracking, and secure digital documentation through Zentake’s HIPAA-compliant platform.
Auditory Vocal Hallucination Rating Scale (AVHRS)
Mental Health
Assesses auditory hallucination characteristics to support accurate monitoring, treatment planning, and secure digital documentation through Zentake’s HIPAA-compliant platform.
Autism Spectrum Quotient (AQ)
Mental Health
Screens for autism-related traits to support early identification, research, and secure digital assessment through Zentake’s HIPAA-compliant platform.
Autism Spectrum Quotient - 10 (AQ-10) (Adolescent)
Pediatrics
Mental Health
Screens for autism-related traits in adults to support early detection, efficient digital workflow, and secure documentation through Zentake’s HIPAA-compliant platform.
Autism Spectrum Quotient - 10 (AQ-10) (Child)
Mental Health
Medical
Screens for autism-related traits in children to support early identification, caregiver insight, and secure digital documentation through Zentake’s HIPAA-compliant platform.
Autism Spectrum Quotient - 10 (AQ-10) (Adult)
Mental Health
Screens for autism-related traits in adults to support early detection, personalized care, and secure digital documentation through Zentake’s HIPAA-compliant platform.
Autism Spectrum Screening Questionnaire (ASSQ)
Mental Health
Pediatrics
Medical
Screens for autism traits in children and adolescents to support early detection, intervention, and informed care planning.
Bath Ankylosing Spondylitis Disease Activity Index (BASDAI)
Medical
Physical Therapy
Assesses disease activity in ankylosing spondylitis to support timely treatment decisions, monitoring, and improved patient outcomes.
Beck Depression Inventory (BDI)
Mental Health
Medical
Screens for depression severity in adolescents and adults to support early detection, treatment planning, and mental health care.
Biopsychosocial Assessment
Medical
Pediatrics
Mental Health
Evaluates biological, psychological, and social factors to support holistic patient care, early intervention, and care planning.
Berg Balance Scale
Medical
Pediatrics
Physical Therapy
Assesses balance and fall risk to support rehabilitation planning, injury prevention, and improved patient mobility.
Bipolar Depression Rating Scale (BDRS)
Mental Health
Medical
Screens for depressive symptoms in bipolar disorder to support accurate diagnosis, treatment planning, and ongoing mental health care.
Foot and Ankle Disability Index (FADI)
Medical
Physical Therapy
Evidence-Based Outcome Measurement Tool for Foot and Ankle Conditions
The Alcohol Use Disorders Identification Test (AUDIT)
Medical
Screens for risky alcohol use to guide brief interventions and treatment referrals.
Drug Abuse Screening Test (DAST-10)
Medical
Mental Health
Screens for drug misuse to identify risk levels and guide early intervention or treatment referrals.
Patient Health Questionnaire - Modified for Teens (PHQ-A)
Medical
Mental Health
Pediatrics
Screens teens for depression to support early intervention, treatment, and improved mental health outcomes.
Pediatric Symptom Checklist (PSC-17)
Medical
Pediatrics
Screens for behavioral and emotional issues in children to guide early intervention and referrals.
Edinburgh Postnatal Depression Scale (EPDS)
Medical
Screens for postpartum depression to support early detection, treatment, and maternal-infant health.
The Disabilities of the Arm, Shoulder and Hand (DASH)
Physical Therapy
Measures upper limb disorder and symptoms to track recovery and support treatment decisions.
Oswestry Low Back Pain Disability Questionnaire
Chiropractic
Physical Therapy
Assesses how low back pain affects daily function to track progress and guide care.

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