Clinical Mental Health Intake Form

This comprehensive intake form helps your clinician prepare for your care. Please complete all sections honestly — there are no right or wrong answers.

Step 1 of 9Demographics

Personal Information

This information helps us provide you with the best possible care.

Emergency Contact

Background

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Care That Is Measured — Because People Are What Matter

Restoring Hope Ministries tracks the well-being of every participant in our clinical and faith-based services using empirically validated screeners, clinical interviews, behavioral analysis, and self-report — so we can honestly see whether the people we serve are getting better. This rigor reflects the training of our founder, Dr. Gross, whose clinical psychology education and practical training at the Medical College of Wisconsin prepared him for this type of organization and care.

Empirically validated screenersClinical interviewsBehavioral analysisSelf-report
See how we measure outcomes and steward your support
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