• Intake Form

    Intake Form

    EFS x MUST Ministries

  • Patient Information

  • Referral Type*
  • Date of Birth*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Race*

  • Gender*
  • Client Type*
  • Client is a Veteran*
  • Client is Disabled*
  • Upload Files
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  • Referred Patient is an Adult?*
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  •  -
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  • Primary Care

  • Do you have or have you ever been diagnosed with any of the following chronic conditions? (Please select all that apply.)

  • Do you use any of the following? (Select all that apply.)*
  • How often do you consume alcohol?*
  • How often do you use tobacco products?*
  • How often do you use recreational drugs?*
  • How often do you engage in physical activity?*
  • Please check any of the following symptoms the patient is experiencing currently:

  • Previous Primary Care Provider

  •  -

  • Behavioral Health

  • Have you received any previous diagnoses related to mental health?*
  • Has the patient been previously diagnosed with any mental health conditions? (Check all that apply.)

  • Please indicate any of the following symptoms the patient has experienced in the past month: (Check all that apply)*

  • Is the patient currently receiving treatment for these conditions?

  • Psychiatric History

  •  -
  • Date of Last Hospitalization
     - -
    2 digit month, 2 digit day, 4 digit year
  • Self-Mutilation?*
  • Date of Last Self-Mutilation
     - -
    2 digit month, 2 digit day, 4 digit year
  • Suicidal Ideation?*
  • Date of Last Ideation?
     - -
    2 digit month, 2 digit day, 4 digit year
  • Suicide Attempts?*
  • Date of Last Attempt?
     - -
    2 digit month, 2 digit day, 4 digit year
  • History of Substance Abuse?*
  • Date of Last Use
     - -
    2 digit month, 2 digit day, 4 digit year
  • Frequency of Substance Use

  • If Complete, Click Submit

  • Should be Empty: