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"]

East Tennessee Psychiatric Services New Patient Intake

Today's Date:

Reason for visit:

Identifying Data

First Name: Middle Initial:Last Name:

Date of Birth:

Social Security Number:

Primary Phone Number:
What type of phone is this:

Do you give East TN Psych. Services permission to call, text, and leave voicemail at this number?

Primary Email:

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

Emergency Contact
Name: Phone:
Relationship to you:

Sex: Gender Identity:

Marital Status:

Street Address:

City: State: Zip:

Who lives in the home with you?

Employment Status:Occupation:Employer:

Highest level of Education:

Religious or Spiritual Preferences:

Are you affiliated with a religious or spiritual organization? If so, please Indicate where:

Psychiatric History

Have you ever been hospitalized for a psychiatric reason? No Yes
If yes, please list the approximate date:

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

Are you currently receiving outpatient psychiatric treatment?
Location of current outpatient psychiatric treatment:
Name of current mental health provider:

Are you in therapy?
Name of current therapist:

If you are not currently under the care of a mental health professional, have you ever been in the past?
If so, where?

Are you currently prescribed any psychiatric medications?
If so, please list any psychiatric medications you are currently taking:

East Tennessee Psychiatric Services New Patient Intake

Result - Copy and paste this output:

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