1. Chief complaint/presenting concern(s) or problem(s):[textarea name="variable_1"]

2. Referral source:[text name="variable_9"]

3. Historical Diagnoses: 
[checklist name="historical" value="ADHD|Bipolar|Schizophrenia|Dememtia|Traumatic Brain Injury|Autism"]

4. Any Psychiatric Medication? [select name="variable_3" value=" |yes= Physician|no = Non-physician"]
[textarea name="variable_1"]

5. Insurance Type: [select name="variable_21" value="Medicare=96127|Medicaid=H0002|Commercial=96127"]

*[calc value="Code = (variable_21)"]*
*[calc value="Level of Care = (variable_3)"]*
1. Chief complaint/presenting concern(s) or problem(s):

2. Referral source:

3. Historical Diagnoses:

4. Any Psychiatric Medication?

5. Insurance Type:

*Code = (variable_21)*
*Level of Care = (variable_3)*

Result - Copy and paste this output:

Sandbox Metrics: Structured Data Index 0.5, 8 form elements, 17 boilerplate words, 1 text boxes, 2 text areas, 1 check lists, 2 drop downs, 2 calculations, 11 total clicks
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