eNotes® Referral & Intake Form
Referral Code:
All fields in blue are required.
First Name:
Last Name:
Middle Name:
Suffix:
Date Of Birth:
Gender:
Male
Female
Unknown
Street:
City:
State:
Zip:
Social Security #:
Insurance Name:
Insurance Id No:
Home Tel:
Bus Tel:
Cell Tel:
Maiden Name:
Nickname:
Marital Status:
Race:
Ethnicity:
Guardian name (if under 18)
Guardian Relationship
Referred by (name):
Referral Source:
Referrer Tel:
Referrer other contact info:
Why Are You Here Today?:
Symptoms Checklist
Anxiety:
Yes
No
No Response
Depression:
Yes
No
No Response
Behavioral issues - aggression/injury/
destruction/taking risks, noncompliance:
Yes
No
No Response
School issues:
Yes
No
No Response
Employment issues:
Yes
No
No Response
Trouble sleeping:
Yes
No
No Response
Decrease in appetite:
Yes
No
No Response
Weight changes:
Yes
No
No Response
Physical illness:
Yes
No
No Response
Martial issues:
Yes
No
No Response
Parenting support
Yes
No
No Response
Adjusting to grief/loss/stressor
Yes
No
No Response
Legal issues
Yes
No
No Response
At Risk For Out Of Home Placement:
Yes
No
No Response
ADHD/ODD:
Yes
No
No Response
ADHD With Resistance To Treatment:
Yes
No
No Response
Disruptive Mood Dysregulation Disorder:
Yes
No
No Response
Psychosis:
Yes
No
No Response
Other:
If you weren't able to be seen here today,
what would you have done?:
Emergency room
No services
Mobile Crisis
Other
No Response
Have you been seen for services in the last 90 days?
Yes
No
No Response
If so, where:
Recommended Service(s):
Recommended Service(s) Other:
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