NBH Intake (under 18 years)

New Patient Intake Form

for children ages 3-17
Updated 3/27/26

This paragraph is updated with wait times and information each month. Please check back for updates.

We will review the availability you provided on your intake form. If we have an opening that matches your availablity, you will hear from us via email about 2 weeks after intake submission with an opening that fits the schedule you provided.

If we do not currently have an opening that matches your availability, you will be added to our waitlist. You will be contacted as soon as we have an opening that matches the schedule you provided.

If you have signed up for an ASAP Intake Evaluation, you will be added to the sign-up the week after intake submission.

Please email bditullio@norwoodbehavioralhealth.com with any questions.

Therapy Waitlist (Individual, Parent, Family)

We currently have a waitlist for therapy sessions. The longest waits are patients who:

(1) Would like to be seen ONLY in-person after 3pm Monday-Friday

(2) Have very limited availabilty

Flexibility to be seen via Telehealth (offered to patients age 10+) with schedule flexibility will shorten your wait for a weekly or biweekly slot.

Current Wait Times

Franklin Office: 1 month

Norwood Office: 4 months

Telehealth: 1 month

"Wait times" are an estimate from the date of intake submission to when a recurring appointment time is offered.

Please note: these wait times may increase or decrease due the number of spots that open each month. Please check back here for updates and waitlist information.

ASAP Intake Evaluations

Our waitlist is a result of our mostly school-aged population requiring after 3pm time slots. We are offering one-time intake evaluations to help shorten our wait times. There is more information on these visit types, as well as a place to indicate interest, later in this form.

You will be added to our email blast for ASAP Intakes the following week after intake submission.

Psychiatry (Medication Management) Waitlist

We do strongly suggest you are in therapy at our practice or elsewhere if you are seeking medication management.

Psychiatry services are currently only offered in the Norwood Office or virtually.

We are currently not able to accept MGBHP Medicaid plans or MassHealth for medication management.

Current Wait Times

Norwood Office: 1 month

Telehealth: 1 month

"Wait times" are an estimate from the date of intake submission to when an intake appointment is offered.

Please note: these wait times may increase or decrease due the number of spots that open each month. Please check back here for updates and waitlist information.

Neurodevelopmental and Psychological Testing Waitlist:

We are now offering Neurodevelopmental and Psychological Testing with Dr. Joyce in the Norwood Office. If you are interested, please select testing as the one of the services you are looking for.

Dr. Joyce is only accepting patients with Blue Cross Blue Shield, Blue Benefit Administrators, and Harvard Pilgim. If you do not have one of these plans, the full testing panel starts at $3,200 (two payments of $1,600).

Current Wait Time

Norwood Office: 2 months

"Wait times" are an estimate from the date of intake submission to when an intake appointment is offered.

Please note: these wait times may increase or decrease due the number of spots that open each month. Please check back here for updates and waitlist information.
Demographics
Child's Legal Name*

First NameMiddle NameLast NameSuffix
Preferred Name
Pronouns*
Date of Birth*

MonthDayYear
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary Phone Number*

Area CodePhone Number
Type of Number*
Phone number belongs to:*
Patient/Mom/Dad/Guardian/Etc.
Secondary Phone Number

Area CodePhone Number
Type of Number
Phone number belongs to:
Patient/Mom/Dad/Guardian/Etc.
Primary Email Address *
Appointment Reminders*
MaleFemaleUnknown
Gender Identity*
If additional gender category or other, please specify
Sexual Orientation*
If other, please specify
UnknownChoose to not discloseOther
Ethnicity*
NoneOther
Religious Affiliation
Smoking Status*
Emergency Contact*

First NameLast Name
Emergency Contact Phone Number*

Area CodePhone Number
Type of Number*
Relationship to Child*
School Name*
Current Grade*
Parent/Guardian Information
Parent/Guardian #1 name*
Parent/Guardian #1 Marital Status*
Parent/Guardian #1 Relationship to Child*
YesNo (if no, please enter address below)
Parent/Guardian #1 Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Parent/Guardian #2 name
Parent/Guardian #2 Marital Status
Parent/Guardian #2 Relationship to Child
YesNo (if no, please enter address below)
Parent/Guardian #2 Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Insurance Information
YesNo
We are CONTRACTED with the following insurance plans:

Blue Cross Blue Shield, Blue Benefit Administrators
Harvard Pilgrim
Health Plans Inc.
MassHealth (must have Massachusetts Behavioral Health Partnership coverage)
Mass General Brigham Health HMO or Medicaid plan (Optum)
United (Optum)
UMR (Optum)
Tufts

We are OUT-OF-NETWORK or NOT ACCEPTING NEW PATIENTS with the following plans:

Aetna
Cigna
ComPsych
Fallon (Carelon)
TriCare
Tufts Health Together (MassHealth/Tufts product)
Tufts Direct (Gold/Silver)
Wellpoint (fka UniCare)
WellSense (Carelon)

If you have an OUT-OF-NETWORK/NOT ACCEPTED insurance plan, you will be required to pay for sessions out-of-pocket. We will provide you with rates when scheduled and a receipt of payment to submit to your insurance company for reimbursement.

Dr. Hamoda (Child and Adolescent Psychiatrist) is ONLY accepting clients with Blue Cross Blue Shield, Blue Benefit Administrators or direct payment.

Dr. Joyce (Testing Psychologist) is ONLY accepting clients with Blue Cross Blue Shield, Blue Benefit Administrators, Harvard Pilgrim or direct payment for testing)
In-Network Insurance Plan*
Out-of-Network Insurance Plan
Subscriber's name*
Subscriber's D.O.B*

MonthDayYear
Insurance Identification # *
Ins. phone # for mental health benefits

Area CodePhone Number
YesNo
If answer to above question is Yes - please provide plan contact name and phone #
YesNo
If yes, what type of secondary insurance do you have?
Secondary Subscriber's name
Subscriber's date of birth

MonthDayYear
Insurance identification #
YesNo
If answer to above question is Yes - please provide plan contact name and phone #
Referral Information
Reason for referral (What is the main problem for which you are seeking help?)*
How often does the problem behavior occur? (5x/day, 2x/week, etc.)*
How long has your child had this problem?*
How is this problem affecting your child at home? In school? In peer relationships?*
If there has been a past evaluation, please bring a copy of the evaluation to the first visit. There is a release of information section at the end of this form.
YesNo
If yes, please provide the previous NBH client's name and name of clinician seen (if none, write none)*
Who referred you to NBH?*
Doctor, friend, Google search, etc.

When would you be able to come for service on a REGULAR basis (weekly/biweekly)? Please check all the apply.*

Rows	Mon.	Tues.	Wed.	Thurs.	Fri.	Sat.
8AM- 12PM
12PM-1PM
1PM-2PM
2PM-3PM
3PM-4PM
4PM-6PM

Individual TherapyFamily TherapyMedication ManagementNeurodevelopmental and Psychological TestingParent Counseling (virtual only)Other
For more information on different services, click HERE.
In-PersonTelehealth (MA residents only, ages 10+)No Preference
NorwoodFranklinNo PreferenceI only want to meet via Telehealth.
Please let us know if you have a preference to see one (or more) of our clinicians. You can find our clinician bios at www.norwoodbehavioralhealth.com
Additional Psychotherapy Session Options:

Our waitlist is a result of our school-aged population requiring after 3pm time slots. We have developed two additional treatment options to help shorten our wait times.

Short-Term Psychotherapy: Short-term treatment is typically more goal-oriented than long-term therapy and tends to focus on specific challenges. Short-term therapy tends to last from about 1-10 sessions, or 1-3 months. The therapist would assess your needs at the first session and determine if you would be a candidate for short-term therapy.

ASAP Intake Evaluation: We have immediate openings for Intake Evaluations. These sessions are 60-minutes long and are used to establish goals, ask questions, identify referrals to other specialities, and collaborate on short-term solutions. Intake appointments are available during the day (M-F, 9-2pm) and are an opportunity to receive an assessment as soon as possible. After Intake, you would return to the waitlist until a weekly or biweekly therapy slot opened with one of our clinicians that matches your schedule availability. Intakes can be seen in-person or via Telehealth.
YesNoI am not looking for psychotherapy (referral for medication management or testing).
YesNoI am not looking for psychotherapy (referral is for testing or medication management or testing).
Medical History
Select your child's primary care doctor (Pediatric Associates of Norwood & Franklin)*
YesNo
If your child's doctor is not on the above list, please enter the group's name, doctor's name, address and phone number (if above, write "above")*
YesNo
Preferred pharmacy (include street and town)*
Medical Drug Allergies (if none, write "none")*
Height*
inches
Weight*
lbs
Date of last known physical (if unknown, approximate date)*

MonthDayYear
Date
List all current medications and supplements taken or needed (if none, write "none")*
If taking any medications, who is the prescribing doctor(s)?
Yes, normalYes, abnormalNoUnknown
YesNo
Age at adoption
YesNo
Identical twinFraternal twin
How long was pregnancy?*
months
Any complications during pregnancy? If so, describe (if none, write "none")*
Any complications during delivery? If so, describe (if none, write "none"*
Any history of developmental delay? If so, describe (if none, write "none")*
Onset age of puberty (if applicable)
years old
The following two questions apply to those assigned as female at birth that have begun their menstrual cycle.
Start date of last menstrual period (approximate if unsure)

MonthDayYear
Date
Birth control method
NoneChronic fatigueChronic painArthritisSeziuresConcussionMigraines/HeadachesGlaucomaHeart DiseaseHigh ChloesterolAsthmaSleep ApneaGastrointestinal IssuesLiver DiseaseKidney DiseaseThyroid DiseaseCancerFrequent infectionsBleeding DisorderOther
Average Number of Hours of Sleep Per Night*
Hours
YesNo
YesNo
Describe any unusual eating habits (picky eater, eating non-edible items, etc.) (If none, write "none")*
Social and Environmental History
With whom does the child currently live?*
YesNo
YesNo
YesNo
If parents are not together, please describe custody agreement
Both parents must consent to services at our practice. If parents are not married and share custody, we will request the second parent completes their own intake form. We will request any additional forms needed at the time of scheduling the first session.

We will provide the opportunity for both parents to attend the first session with the clinician and will accomodate separate appointments if requested.

Please note: we may also request a copy of any legal documentation outlining the custody agreement at the start of services.

Regardless of married status, both parents (assuming there is legal custody) must be onboard with services for us to start and/or continue treatment.
I acknowledge both parents consent to psychiatry, testing and/or psychotherapy services. We agree to complete any additional forms if requested by the practice or clinician.
Any academic or social difficulties at school? (If none, write "none")*
YesNo

Please indicate where you feel your child is performing academically*

Rows	Below Grade Level	On Grade Level	Above Grade Level
Language Arts
Mathematics
Writing

YesNo
Is your child currently on a 504 plan? If yes, what is your child's diagnosis and the 504 Plan intervention? Do you feel it is effective?*
Date of Most Recent IEP

MonthDayYear
Date
Does your child have difficulty with siblings?*
Has the child ever been placed or boarded away from the family? If so, describe (if no, write "no"*
Does your child have any past or current legal involvement? (If none, write "none")*
Does your child belong to any spiritual or religious group? (If none, write "none")*
Psychiatric History
Please list any psychiatric disorder your child has been diagnosed with in the past (if none, write "none")*
YesNoUnsure
If so, when? (If none, write "none")*
YesNoUnsure
If so, when? (If none, write "none")*
List any psychiatric medications prescribed in the past (if none, write "none")*
YesNoUnknownOther
If yes, when?
YesNoUnknownOther
If yes, when?
YesNoUnsureOther
If yes, when?
YesNoUnknownOther
If yes, when?
YesNoUnknownOther
If yes, when?
Please call 911 for any immediate safety concerns.
Family Psychiatric History
AlcoholismAddictionSchizophreniaAutism Spectrum DisordersADHDDepressionBipolar DisorderSuicide (threats/attempts/completed)AnxietyPhobiasPsychiatric hospitalizationsNoneOther
If yes to any of the above, specify the relationship and if the relationship is maternal or paternal (if none, write "none")*
Substance Use History
YesNoUnsure
If yes, which substances? (If none, write "none")*
If yes, when was the child last treated? (if never, write "never")*
If your child drinks, how may days a week do they drink alcohol? (If they do not drink, write "none")*
YesNoUnsure
If yes, how often? (If never, write "never")*
YesNoUnsure
If yes, what and when? (If never, write "never")*
How many caffeinated beverages does your child drink in a day?*
drinks per day
YesNoUnsure

Confidentiality, Consent & Financial Agreement
Each staff member makes every effort to safeguard the legal and civil rights of each client at all times regarding the treatment process and discharge from the treatment process. As a client of Norwood Behavioral Health, you have the right to:
- Know about our professional qualifications.
- Know about and comment on the agency's policies and procedures.
- See and discuss our fee scale.
- See and comment orally and/or in writing on the record kept of your contact with this agency and insert your own statement if you wish.
- Discuss any concerns with your clinician, and if you desire, have a three-way conference including you, your clinician, and their supervisor.
- Make suggestions as to how our policies and services can be improved.
  You have the right to refuse any services offered.
CONFIDENTIALITY

All services rendered while you are in treatment at Norwood Behavioral Health are held in strict confidence. Our policies and procedures protect your privacy to the fullest extent of the law. Since your discussions with staff are confidential, the agency ordinarily will not disclose information about you and to anyone else without your written permission. Similarly, the agency cannot request information about your from others without your written permission. Under the law, there are some exceptions to the normal protection of your privacy. For example the agency must disclose the information it considers necessary in order to protect someone’s life or when a specific law requires disclosure. Similarly, a court order waves confidentiality.

INFORMED CONSENT

I have reviewed the above. I give CONSENT for TREATMENT and understand I have the right to revoke this consent at any time.

FINANCIAL AGREEMENT

I authorize my insurance benefits be paid directly to the physician. I understand that I am financially responsible for any balance. I also authorize Norwood Behavioral Health or my insurance company to release any information requeired to process my claims.

MISSED APPOINTMENT POLICY

By signing below, you are indicating you agree to and understand that all appointments must be cancelled within 24-hours. You may contact your provider via email or phone. All missed appointments may result in a fee of $75 for therapy sessions or $100 for psychiatry sessions.

INTAKE POLICY

By signing below, you understand the first visit at our practice is 60-minute intake appointment. After this evaluation, if the clinician feels our practice is not suitable for your needs, we will help to facilitate a referral to an appropriate facility.
Signature*

Clear
Name*

First NameLast Name
Relationship to Patient*
Thank you for completing our intake form. We will review your information and contact you when we have a match for the availability you indicated above. Intakes are reviewed in the order in which they were received. Waitlist information is updated monthly at the top of this form, which can be found on our website homepage.
Should be Empty:

New Patient Intake Form

Demographics

Parent/Guardian Information

Insurance Information

Referral Information

Medical History

Social and Environmental History

Psychiatric History

Family Psychiatric History

Substance Use History

Release of Information

Confidentiality, Consent & Financial Agreement