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"]
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