Patient_ID
  Do Not enter any information in this field

First_Name
 

Last_Name
 

Social_Sec_Number
  Format 123456789

Date_of_Birth
  Format mm/dd/yyyy

Age
  Do Not enter the age. It would be calculated once the database is exported

Ethnicity
 

Sex
 

Religion
 

Address
 

Apt_Number
 

City
 

State
 

Zip_Code
 

Phone_Number
  Format (123) 456-7890

Parent_Leg_Guardian
 

Parent_Leg_Guard_Phone
 

Primary_Care_Doc
 

PCP_Phone
 

Presenting_Problem
 

Occupation
 

Insurance
 

Date_of_Referral
 

Referral_Source
 

Agent
 

Ref_Phone_Number
 

Initial_Apt_Date
 

Appointment_Time
 

Staff_Assigned
 

Program_Site
 

Psychiatrist
 

Language
 

Referral_Received_By
 

Patient Status
  A = Active. I = Inactive (Do not forget to update chart accordingly to include the inactive date)