EFS Referral Form 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 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
Date
YesNo
MaleFemaleGender Non ConformingChoose not to Disclose
Race
Primary Insurance Type*
Primary Insurance Number*
Secondary Insurance Number
Secondary Insurance Type
Social Security Number
YesNo
Parent / Guardian*

First NameLast Name
Relationship
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Alternate Phone Number
Emergency Phone Number
Email*
example@example.com
Primary Language
Please indicate whether this referral is from DFCS, the Department of Juvenile Justice, or a Mental Health Hospital.
YesNo
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
Fax Number
Case Manager Email
Supervisor's Name
Supervisor's Phone Number
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
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Group HomeFoster HomeTemp HousingExtended HousingNon-Relative (Fictive Kin)Other
YesNo
YesNo
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
Probation Officer Fax
Probation Officer Email
example@example.com
Supervisor's Name
Presenting Charge / Offense
Next Court Date

MonthDayYear
Date
YesNo
Mental / Behavioral Health Hospital Referral:
Additional Supporting Documents

Browse Files
Admission paperwork, discharge summary, last progress note, etc Cancelof
Name of Facility
Phone Number
Fax Number
Admission Date

MonthDayYear
Date
Discharge (Anticipated) Date

MonthDayYear
Date
Presenting Problems at Time of Admission
Discharging Therapist
Direct Contact Number
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 *
Physical / Verbal AggressionAnxietyConduct ProblemsDepressed MoodElevated MoodFamily ProblemsGender IssuesGriefHyperactivityIndependent Living ProblemsIrritabilityMood SwingsOppositional / Defiant BehaviorsPoor ConcentrationPoor Interpersonal SkillsPoor JudgementPTSD/TraumaHome / Work / School ProblemsSelf-Harming / Dangerous BehaviorsThoughts of SuicideHistory of AbuseWorthlessnessAt-Risk of Legal SystemSubstance UseCourt OrderedSexually Acting OutOther
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.
Telehealth (Virtual)In Office (Atlanta)In Office (Douglasville)In Office (Cartersville)Hybrid (Telehealth + In Atlanta Office)Hybrid (Telehealth + In Cartersville Office)Hybrid (Telehealth + In Douglasville Office)Hybrid (Telehealth + In Community)In Community
For patient safety and to ensure medication effectiveness, in-person nursing assessments are required for all patients on medication
MaleFemaleNo Preference
Weekday Mornings (e.g., 8 AM – 12 PM)Weekday Afternoons (e.g., 12 PM – 4 PM)Weekday Evenings (e.g., 4 PM – 8 PM)Weekend MorningsWeekend AfternoonsWeekend Evenings
MondayTuesdayWednesdayThursdayFridaySaturdaySunday
YesNot SureNot at this Time
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
YesNoOther
Previous Psychiatrist
Contact Info
YesNoOther
Current Medications (Name, Dosage, Frequency)
YesNo
Prescribing Provider's Name
YesNoOther
Number of Psychiatric Hospitalizations:
Approximate Dates & Reasons:
YesNoOther
Please Describe
YesNoOther
How frequently do you experience these thoughts?
YesNoOther
Number of past attempts
Approximate dates
YesNoOther
AlcoholMarijuana (Cannabis)TobaccoOpioids (e.g., Heroin, Prescription Painkillers)Stimulants (e.g., Cocaine, Methamphetamine)Prescription Medications (Misuse)Hallucinogens (e.g., LSD, Psilocybin)Sedatives/Tranquilizers (e.g., Benzodiazepines)InhalantsOther
Frequency of Use:
Date of Last Use:

MonthDayYear
Date
YesNoOther
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