Referral - EFS 2.0

Behavioral Health Intake Form
This form is for Eastchester Family Services Behavioral Health Program which includes both Therapy and Psychiatric services. Please note that we do not offer medication management without therapy.

If you are DFCS and ONLY need Testing and/or Evaluations, please use the DFCS Referral Form. Also available on our forms page.
Personal Information
Legal Name

First NameMiddle NameLast Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Have you received services from Eastchester Family Services in the Past?
Gender
Race
Primary Insurance Type
Primary Insurance Number
Secondary Insurance Number
Secondary Insurance Type
Social Security Number
Referred Patient is an Adult?
Parent / Guardian

First NameLast Name
Relationship
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Format: 000-000-0000.
Alternate Phone Number
Format: 000-000-0000.
Emergency Phone Number
Format: 000-000-0000.
Email
example@example.com
Primary Language
Please indicate whether this referral is from DFCS, the Department of Juvenile Justice, or a Mental Health Hospital.
Department of Family & Children Services Case
Division of Family and Children Services Referral:
DFCS Supporting Documents

Browse Files
Completed CCFA, Trauma Assessment, Psychological, etc. Cancelof
County
Case Manager Name
Phone Number
Format: 000-000-0000.
Fax Number
Format: 000-000-0000.
Case Manager Email
Supervisor's Name
Supervisor's Phone Number
Format: 000-000-0000.
Supervisor's Email
Placement Information (if other than Biological Parent or Legal Guardian)

Please submit copy of Guardianship / Placement Agreement
DFCS Supporting Documents

Browse Files
Guardian/Placement Agreement Cancelof
Name or Agency
Contact Number
Format: 000-000-0000.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Type

Other
Monthly Summary Required?
Additional Testing Needed?
Court Ordered? (Drug Court, Dept. of Juvenile Justice, etc.)
Department of Juvenile Justice / Court Referral:
DJJ Supporting Documents

Browse Files
Completed CCFA, court recommendations, probation order, etc. Cancelof
County
Probation Officer Name
Probation Officer Phone
Format: 000-000-0000.
Probation Officer Fax
Format: 000-000-0000.
Probation Officer Email
example@example.com
Supervisor's Name
Presenting Charge / Offense
Next Court Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Mental/Behavioral Health Hospital Referral?
Mental / Behavioral Health Hospital Referral:
Additional Supporting Documents

Browse Files
Admission paperwork, discharge summary, last progress note, etc Cancelof
Name of Facility
Phone Number
Format: 000-000-0000.
Fax Number
Format: 000-000-0000.
Admission Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Discharge (Anticipated) Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Presenting Problems at Time of Admission
Discharging Therapist
Direct Contact Number
Format: 000-000-0000.
Medications Prescribed
Discharging Mental Health Diagnosis(es)
Supporting Documents

Browse Files
Please submit any documentation supporting the above diagnosis(es) Cancelof
Reason for Visit
Referral Source Type
Choose the most relevant reason from the list above.
Referral Completed By (Name)
Referring Person’s Full Name
Referral Source Contact Information
Please provide the best phone number or email for follow-ups on this referral.
Brief Description of Presenting Problems & Reasons for Seeking Services
Symptom / Problem Checklist

Other
Therapy Preferences
Please note that indicating your preferred days and times helps us in scheduling, but we cannot guarantee these specific slots. We will do our best to accommodate your schedule based on therapist availability.
How would you like to see your therapist?
For patient safety and to ensure medication effectiveness, in-person nursing assessments are required for all patients on medication
Do you have a preference regarding the gender of your therapist?
Which days and times do you typically prefer for therapy sessions? (Select all that apply.)
If you selected any weekday availability, please indicate which specific weekdays work best for you.(Check all that apply)
Would you like to be assigned a family advocate?
Family Advocates work alongside the therapist to provide connections to community resources, teach coping skills, and help improve daily functioning at home, school and/or work settings.
Medical & Psychiatric Background
Do you have a Primary Care Provider?
Have you seen a Psychiatrist in the Past?

Other
Previous Psychiatrist
Contact Info
Are you currently on any Medications?

Other
Current Medications (Name, Dosage, Frequency)
Are you taking your medications as prescribed?
Prescribing Provider's Name
Have you ever been hospitalized for psychiatric reasons?

Other
Number of Psychiatric Hospitalizations:
Approximate Dates & Reasons:
Have you ever engaged in self-harming behaviors?

Other
Please Describe
Do you currently experience suicidal thoughts?

Other
How frequently do you experience these thoughts?
Have you ever attempted suicide?

Other
Number of past attempts
Approximate dates
Do you use or have you used any substances (e.g., Alcohol, Marijuana, Opioids)?

Other
Substance(s) Used:

Other
Frequency of Use:
Date of Last Use:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Do you have any other significant health conditions (e.g., diabetes, heart disease, allergies)?

Other
Please list and describe:
For example, hypertension, diabetes, high blood pressure, seizures, etc.
Supporting Documents

Browse Files
For example: past evaluations, recent lab results, medicals reports, etc. Cancelof
Admin Notes
Notes:
Should be Empty:

Division of Family and Children Services Referral:

Department of Juvenile Justice / Court Referral:

Mental / Behavioral Health Hospital Referral:

Reason for Visit

Therapy Preferences

Medical & Psychiatric Background