East Tennessee Psychiatric Services New Patient Intake

East Tennessee Psychiatric Services New Patient Intake

Today's Date: [date name="Date"]

Reason for visit:[textarea name="presenting problem"]

Identifying Data

First Name:[text name="Patient's name" size="10"] Middle Initial:[text name="Patient's name" size="5"]Last Name:[text name="Patient's name" size="10"] 

Date of Birth:[date name="Date of birth"]

Social Security Number:[text name="SSN" size="20"]

Primary Phone Number:[text name="Phone" size="30"] 
What type of phone is this:[select name="phone" value="Home|Cell|Work|Other"]

Do you give East TN Psych. Services permission to call, text, and leave voicemail at this number? [select name="phone" value="Yes|No"]

Primary Email:[text name="email" size="50"]

Do you give East TN Psych. Services permission to communicate with you via this email address? (email is NOT considered a secure form of communication. Sensitive data will never be sent via email [select name="email" value="Yes|No"]

Emergency Contact
Name:[text name="EC " size="20"] Phone:[text name="EC " size="20"]
Relationship to you:[text name="EC " size="20"]

Sex:[select name="Sex" value="|Female|Male|Other|Prefer not to say"] Gender Identity:[select name="GI" value="|Male|Female|Transgender|Non-Binary|Intersex|Other|Prefer not to say"]

Marital Status:[select name="Marital Status" value="|Single|Married|Long-term partner|Separated|Divorced|Widowed|Other"]

Street Address: [text name="address" size="30"] 

City:[text name="address" size=25"] State:[select name="State" value="AL|AK|AZ|AR|CA|CO|CT|D.C.|DE|FL|GA|HI|ID|IL|IN|IA|KS|KY|LA|ME|MD|MD|MA|MI|MN|MS|MO|MT|NE|NV|NH|NJ|NM|NY|NC|ND|OH|OK|OR|PA|RI|SC|SD|TN|TX|UT|VT|VA|WA|WV|WI|WY|"] Zip:[text name="address" size="10"]

Who lives in the home with you?
[textarea name="Home "]

Employment Status:[select name="job" value="Full-time|Part-time|Self-employed|Student|Retired|Disabled|Unemployed"]Occupation:[text name="job" size="20"]Employer:[text name="job" size="20"]

Highest level of Education:[text name="job" size="20"]

Religious or Spiritual Preferences:[text name="job" size="20"]

Are you affiliated with a religious or spiritual organization? If so, please Indicate where:[text name="job" size="50"]


Psychiatric History

Have you ever been hospitalized for a psychiatric reason? [radio name="Have you ever been hospitalized for a psychiatric reason?" value="No|Yes"] 
If yes, please list the approximate date:[text name="psych" size="20"]

If you answered "yes", please indicate how many times you have been psychiatrically hospitalized:[text name="psych" size="20"]
Please indicate the name or locations of the facility(s) you have been hospitalized:[text name="psych" size="20"] 
How old were you when you were first hospitalized?[text name="psych" size="10"] 
Please list the reason(s) for your hospitalization(s):[text name="psych" size="20"]

Are you currently receiving outpatient psychiatric treatment? [select name="psych" value="Yes|No"] 
Location of current outpatient psychiatric treatment: [text name="psych" size="20"]
Name of current mental health provider: [text name="psych" size="20"] 

Are you in therapy? [select name="psych" value="Yes|No"]
Name of current therapist: [text name="psych" size="20"] 

If you are not currently under the care of a mental health professional, have you ever been in the past? [select name="psych" value="Yes|No"] 
If so, where? [text name="psych" size="20"] 

Are you currently prescribed any psychiatric medications? [select name="psych" value="Yes|No"]
If so, please list any psychiatric medications you are currently taking: [textarea name="Meds"]