• MUST Community Clinic

    MUST Community Clinic

    Eastchester Family Services Intake Form

  • Patient Information

  • Referral Type*
  • Date of Birth*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Do you have insurance?*

  • 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

  • Referred Patient is an Adult?*
  •  -
  •  -
  •  -
  • Race*

  • Gender*
  • Client is a Veteran*
  • Client is Disabled*
  • Upload Files
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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: