Intake Form
EFS x MUST Ministries
Patient Information
Referral Type
*
Primary Care
Behavioral Health
Both
Legal Name
*
First Name
Middle Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Race
*
Asian or Pacific Islander
Bi-racial
Black or African American
European
Latin American/Hispanic
Native American or American Indian
Unknown
White
Choose not to Disclose
Other
Gender
*
Male
Female
Gender Non Conforming
Choose not to Disclose
Client Type
*
Hope House - Resident
Hope House - Outreach
Client Services – Marietta
Permanent Supportive Housing - Marietta
Permanent Supportive Housing - Canton
Smyrna Client Services
Client is a Veteran
*
Yes
No
Choose not to Disclose
Client is Disabled
*
Yes
No
Choose not to Disclose
If yes, please describe:
Please attach any relevant documents or files that support your referral.
Upload Files
This could include: previous assessments, medical reports, consent forms, etc.
Cancel
of
Insurance Number
Insurance Type
Name of insurance
Referred Patient is an Adult?
*
Yes
No
Parent/Guardian Relationship
Parent/Guardian Name
First Name
Last Name
Parent / Guardian Email
example@example.com
Phone Number
-
Area Code
Phone Number
Alternative Phone Number
-
Area Code
Phone Number
Emergency Phone Number
-
Area Code
Phone Number
Client Email
example@example.com
Referral By
*
Case Manager Name
Case Manager Phone Number
*
-
Area Code
Phone Number
Case Manager Email
*
example@example.com
Back
Next
Primary Care
What is the primary reason for the referral to primary care?
*
Please list any medications the patient is currently taking:
(Include prescription medications, over-the-counter drugs, and any supplements.)
Do you have or have you ever been diagnosed with any of the following chronic conditions? (Please select all that apply.)
Hypertension (High Blood Pressure)
Diabetes (Type 1 or Type 2)
Heart Disease (e.g., Coronary Artery Disease, Congestive Heart Failure)
Chronic Respiratory Conditions (e.g., Asthma, COPD)
Arthritis (e.g., Osteoarthritis, Rheumatoid Arthritis)
Chronic Kidney Disease
Liver Disease (e.g., Hepatitis, Cirrhosis)
Thyroid Disorders (e.g., Hypothyroidism, Hyperthyroidism)
Mental Health Conditions (e.g., Depression, Anxiety Disorders, Bipolar Disorder)
Neurological Conditions (e.g., Epilepsy, Multiple Sclerosis)
Gastrointestinal Disorders (e.g., Crohn's Disease, Ulcerative Colitis, Irritable Bowel Syndrome)
Autoimmune Diseases (e.g., Lupus, Type 1 Diabetes)
Osteoporosis
Cancer (Please specify type: ____________)
Other
Is there a family history of chronic diseases?
(Include conditions such as diabetes, hypertension, cardiovascular disease, or cancer.)
List any surgeries or hospitalizations the patient has had:
(Please include dates and reasons if possible.)
Does the patient have any known allergies?
(Include drugs, food, or environmental factors.)
Do you use any of the following? (Select all that apply.)
*
Tobacco products
Alcohol
Recreational drugs
None
How often do you consume alcohol?
*
Daily
Several times a week
Once a week
Rarely
Never
How often do you use tobacco products?
*
Daily
Several times a week
Once a week
Rarely
Never
How often do you use recreational drugs?
*
Daily
Several times a week
Once a week
Rarely
Never
How often do you engage in physical activity?
*
Daily
Several times a week
Once a week
Rarely
Never
Please check any of the following symptoms the patient is experiencing currently:
Fever
Shortness of breath
Chest pain
Unexplained weight loss/gain
Fatigue
Persistent cough
Difficulty sleeping
Headaches
Dizziness
Abdominal pain
Other
Previous Primary Care Provider
Primary Care Provider
Primary Care Physician
First Name
Last Name
PCP Contact Information
-
Area Code
Phone Number
Back
Next
Behavioral Health
What is the primary reason for the referral for behavioral health?
*
Have you received any previous diagnoses related to mental health?
*
Yes
No
If Yes, please provide the specific mental health diagnosis(es) received.
Please list any medications the patient is currently taking:
(Include prescription medications, over-the-counter drugs, and any supplements.)
Has the patient been previously diagnosed with any mental health conditions? (Check all that apply.)
Depression
Anxiety Disorders (e.g., Generalized Anxiety Disorder, Panic Disorder)
Bipolar Disorder
Schizophrenia
Post-Traumatic Stress Disorder (PTSD)
Eating Disorders (e.g., Anorexia, Bulimia)
Substance Use Disorders
Attention-Deficit/Hyperactivity Disorder (ADHD)
Autism Spectrum Disorder (ASD)
Other
Please indicate any of the following symptoms the patient has experienced in the past month: (Check all that apply)
*
Physical / Verbal Aggression
Anxiety
Conduct Problems
Depressed Mood
Elevated Mood
Family Problems
Gender Issues
Grief
Hyperactivity
Independent Living Problems
Irritability
Mood Swings
Oppositional / Defiant Behaviors
Poor Concentration
Poor Interpersonal Skills
Poor Judgement
PTSD/Trauma
Home / Work / School Problems
Self-Harming / Dangerous Behaviors
Thoughts of Suicide
History of Abuse
Worthlessness
At-Risk of Legal System
Substance Use
Court Ordered
Sexually Acting Out
Other
Is the patient currently receiving treatment for these conditions?
Yes
No
Date and Time of Therapy Appointment
Psychiatric History
Psychiatrist
Psychiatrist Phone Number
-
Area Code
Phone Number
Number of Hospitalizations
Date of Last Hospitalization
-
Month
-
Day
Year
Date
Extent of Last Hospitalization
Self-Mutilation?
*
Yes
No
Date of Last Self-Mutilation
-
Month
-
Day
Year
Date
Suicidal Ideation?
*
Yes
No
Date of Last Ideation?
-
Month
-
Day
Year
Date
Suicide Attempts?
*
Yes
No
Date of Last Attempt?
-
Month
-
Day
Year
Date
History of Substance Abuse?
*
Yes
No
Date of Last Use
-
Month
-
Day
Year
Date
Substances of Choice:
Frequency of Substance Use
Daily
Weekly
Monthly
Rarely
Socially
Never
Back
Next
If Complete, Click Submit
Email
example@example.com
Submit
Should be Empty: