POE Forms – Keystone Behavioral Health

Are you registered to vote?

Yes

No

TB: OK Response from I/P nurse

Do you have a primary care physician?

Yes

No

If yes, give the physicians name:

Physician Name

Are you pregnant?

Yes

No

Are you American Indian?

Yes

No

Are you a Catawba Mental Health Patient?

Yes

No

Patient Name(Required)

First Middle Last Suffix

Date(Required)

Email(Required)

DOB(Required)

Primary Phone(Required)

Country Phone Number

Type

Cell

Home

Other

Ok to leave a message?

Yes

No

Phone #2

Country Phone Number

Type

Cell

Home

Other

Ok to leave a message?

Yes

No

Phone #3

Country Phone Number

Type

Cell

Home

Other

Ok to leave a message?

Yes

No

Address

Street Address City County State / Province / Region ZIP / Postal Code Country

Mailing Address (If different than physical address):

Street Address City County State / Province / Region ZIP / Postal Code Country

Gender

Male

Female

Tobacco

User

Non-user

Gender Identity

Choose not to disclose

Identifies as male

Identifies as female

Female-to-Male (FTM)

Genderqueer

Other

Smoking Status

Current

Former

Never

Race

Black

White

Asian

American Indian

Native Hawaiian/Other Pacific Islander

Alaskan Native

Other Single Race

Two or More Races

Unknown

Primary Language

Ethnicity

Cuban

Mexican

Puerto Rican

Not of Hispanic Origin

Unknown

Need Interpeter

Yes

No

Marital Status

Divorced

Currently Married

Separated

Never Married

Widowed

Military Status

Yes

No

Unknown

Referral Source: What agency or individual referred the patient to Keystone?

Employment Information

Employment Status

Part-Time

Full-Time

Unemployed

Occupation

Job Title

Number of days worked in the last 30 days:

If Not in Labor Force, why?

Disabled

Homemaker

In Institutional Care

Inmate

Retired

Education

Highest grade level completed (# of years):

Degree Earned

Household Information

Annual Household Income

Individuals in your Household

Individuals under 18 in your Household

Principal Income Source

Wages/Salary

Public Assistance

Retirement/Pension

Disability

Other

Do you plan to apply for Financial Assistance?

Yes

No

Be prepared to supply staff with Proof of Residency, 2 recent check stubs, last signed Fed/State tax return, Social Security eligibility letter, proof of other income, proof of dependents. Call 803-325-1800 for more information.

Emergency Contact

Name

First Last

Relationship to Patient

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Country Phone Number

Ok to leave a message?

Yes

No

POE Form

Employment Information

Education

Household Information

Emergency Contact

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