MUST Community Clinic Intake Form

Primary CareBehavioral HealthBoth

Legal Name*

First NameMiddle NameLast Name

Date of Birth*

Date

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

YesNo

Sliding Fee Scale Application

It is the policy of Eastchester Family Services (EFS) to provide essential services regardless of the client’s ability to pay. EFS offers discounts based on family size and annual income.
Please complete the following information and return to the front desk to determine if you or members of your family are eligible for a discount.
The discount will apply to all services received at this clinic, but not those services or equipment purchased from outside, including reference laboratory testing, medicines, x-ray interpretation by a consulting radiologist, and other such services. You must complete this form every 12 months or if your financial situation changes

Please list all household members, including those under age 18.

Name & Date of Birth.

Gross wages, salaries, tips, etc.

Income from business and self-employment

Unemployment compensation, workers' compensation, Social Security, Supplemental Security Income, veterans' payments, survivor benefits, pension or retirement income

Interest; dividends; royalties; income from rental properties, estates, and trusts; alimony; child support; assistance from outside the household; and other miscellaneous sources

I certify that the family size and income information shown above is correct.

Insurance Number

Insurance Type

Name of insurance

YesNo

Parent/Guardian Relationship

Parent/Guardian Name

First NameLast Name

Parent / Guardian Email

example@example.com

Phone Number

Area CodePhone Number

Alternative Phone Number

Area CodePhone Number

Emergency Phone Number

Area CodePhone Number

Client Email

example@example.com

MaleFemaleGender Non ConformingChoose not to Disclose

YesNoChoose 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.

MUST Community Clinic

Patient Information

Primary Care

Previous Primary Care Provider

Behavioral Health

Psychiatric History

If Complete, Click Submit