NBH Intake (age 18-24)

New Patient Intake Form

for adults ages 18-24
Updated 2/8/23

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

Therapy Waitlist:

We currently have a waitlist for therapy sessions. Please note these wait times may change due the number of spots that open each month. Please check back here for updates and waitlist information.

Approximate therapy wait time FOR Pediatric Associates of Norwood and Franklin or Karuna Patients: 4 months

Approximate therapy wait time FOR NON-Pediatric Associates of Norwood and Franklin or Karuna Patients: 4 months

Short-Term Psychotherapy & ASAP Intake Evaluations: Our waitlist is a result of our mostly school-aged population requiring after 3pm time slots. We have developed two additional treatment options to help shorten our wait times.We are offering short-term and 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.

Medication Management Waitlist:

We currently have a waitlist for medication management sessions. Please note these wait times may change due the number of spots that open each month. Please check back here for updates and waitlist information.

We are only able to take on new medication management patients with Blue Cross Blue Shield or private pay at this time.

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

Approximate medication management wait time: 1 month
Demographics
Legal Name*

First NameLast Name
Birth Sex*

MaleFemaleUnknown
Date of Birth*

MonthDayYear
Preferred Name
Pronouns*
Email Address *
example@example.com
Languages spoken other than English*

None
Gender Identity*
If additional gender category or other, please specify
Sexual Orientation*
If something else, please describe
Race*

UnknownChoose to not disclose
Ethnicity*
Marital Status*
Employment*
Religious Affiliation
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary Phone Number*

Area CodePhone Number
Type of Number*
Secondary Phone Number

Area CodePhone Number
Type of Number
Emergency Contact*

First NameLast Name
Emergency Contact Phone Number*

Area CodePhone Number
Relationship*
Parent/Guardian Information

(if applicable)
Parent/Guardian #1

First NameLast Name
Parent/Guardian #1 Marital Status
Parent/Guardian #1 Relationship to Client
mother, father, etc.
Is Parent/Guardian #1 address the same as the client?

YesNo (if no, please enter address below)
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Guardian #2

First NameLast Name
Parent/Guardian #2 Marital Status
Parent/Guardian #2 Relationship to Client
mother, father, etc.
Is Parent/Guardian #2 address the same as the client?

YesNo (if no, please enter address below)
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Insurance Information
Do you anticipate using your health insurance to pay for services at NBH?*

YesNo
We are CONTRACTED with the following insurance plans:
- Blue Cross Blue Shield
- Cigna
- Massachusetts Behavioral Partnership (MassHealth)
- Optum Behavioral Health (Mass General Brigham Health Plan (f.k.a AllWays), Harvard Pilgrim and United)
- Tufts
We are OUT-OF-NETWORK with the following insurance plans:
- Aetna
- BMC Healthnet
- ComPsych
- Fallon
- TriCare
- Tufts Health Together (MassHealth/Tufts product)
- Tufts Direct (Gold/Silver)
- UniCare
If you have an OUT-OF-NETWORK insurance plan, you will be required to pay at the time of service. We will provide you with a receipt of payment to submit to your insurance company for reimbursement.

Dr. Hamoda (Child and Adolescent Psychiatrist) is ONLY contracted with Blue Cross Blue Shield.
In-Network Insurance plan*
Out-of-Network Insurance plan
Subscriber's name*
Subscriber's D.O.B*

MonthDayYear
Insurance Identification # *
Is your health insurance plan either: a union plan, employer self-funded plan, or a trust plan?*

YesNo
If answer to above question is yes, please provide plan contact name and phone #
Do you have secondary insurance?*

YesNo
If yes, what type of secondary insurance do you have?
Secondary Subscriber's name
Subscriber's date of birth

MonthDayYear
Insurance identification #
Is your health insurance plan either: a union plan, employer self-funded plan, or a trust plan?

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 have you had this problem?*
How is this problem affecting you at home? In school? In friendships/romantic relationships?*
If there has been a past evaluation, please bring a copy of the evaluation to the first visit. We will have you complete a consent form to allow us to communicate with your prior/current professional.
Have you or other immediate family members been seen at Norwood Behavioral Health before?*

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.
If you are requesting a specific provider please select here:
If you do not have a specific provider request, leave blank

When would you be able to come for service on a regular basis? Please check all the apply.*

	Mon.	Tues.	Wed.	Thurs.	Fri.	Sat.
8 AM - Noon
Noon - 3 PM
3 PM - 6 PM
6 PM - 9 PM

Services requested:*

Medication ManagementIndividual TherapyFamily TherapyParent Counseling
Preferred Visit Type*

In-PersonTelehealth (MA residents only)No Preference
Preferred In-Person Location*

NorwoodFranklinNo PreferenceI only want to meet via Telehealth.
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.
I am interested in Short-Term Psychotherapy.*

YesNoI am not looking for psychotherapy (referral is for medication management onnly).
I am interested in an ASAP Intake Evaluation.*

YesNo
Medical History
Select your primary care doctor*
Are you a patient at Karuna: Nutrition + Movement?*

YesNo
If your doctor is not on the above list, please enter the group's name, the doctor's name, address and phone number*
Do you give permission for ongoing updates to be provided to your PCP including but not limited to lab work and medication changes?*

YesNo
Preferred pharmacy (Please include street and town)*
Medical drug allergies (if none, write "none")*
Height*
inches
Weight*
lbs
Date of last physical exam (if unknown, approximate date)*

MonthDayYear
Date
List all current medications and supplements taken or as needed (if none, write "none")*
List any past medical (non-psychiatric) hospitalizations or surgeries (if none, write "none")*
Have you ever had an EKG?*

NoYes, NormalYes, AbnormalUnknown
Were you adopted?*

YesNo
Age at adoption
years old
Are you a twin (or other multiple)?*

YesNo
If a twin, identical?

Identical twinFraternal twin
How long was your mother's pregnancy with you?*
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*
years old
The following few questions apply to those assigned as female at birth:
Start date of last menstrual period (approximate if unsure)

MonthDayYear
Date
Are you currently pregnant or think you might be pregnant?

YesNoUnsure
Are you planning to get pregnant in the near future?

YesNoUnsure
Birth control method
How many times have you been pregnant (live births)?
Have you had a miscarriage?

YesNoUnsure
If so, how many?
Please indicated illness or disease you have had*

Chronic fatigueChronic painArthritisSeizuresConcussionMigraines/HeadachesGlaucomaHeart DiseaseHigh ChlolesterolHigh Blood PressureAsthmaSleep ApneaGastrointestinal IssuesLiver DiseaseKidney DiseaseDiabetesThyroid DiseaseCancerFrequent infectionsBleeding disorderNone
Average Number of Hours of Sleep Per Night*
hours
Frequent or Waking Nightmares?*

YesNo
Any recent weight loss or gain?*

YesNo
Describe any unusual eating habits (picky eater, eating non-edible items, etc.) (If none, write "none")*
Social and Environmental History
Are you currently*

MarriedSingleWidowedDivorcedPartnered
With whom do you currently live?*
Are you in a relationship?*

YesNoUnsure
Do you feel safe in this relationship?*
Highest level of education*
High School, College, Graduate School
Any academic or social difficulties during schooling? (if none, write "none")*
Are you currently*

StudentUnemployedDisabledRetired
Occupation (if none, write "none")*
Do you belong to any spiritual or religious group? (if none, write "none")*
Do you have any past or current legal involvement? (if none, write "none")*
Psychiatric History
Please list any psychiatric disorder you have been diagnosed with in the past (if none, write "none")*
Have you ever received outpatient treatment for a psychiatric disorder?*

YesNoUnsure
If so, when? (if none, write "none)*
Inpatient hospitalizations?*

YesNoUnsure
If so, when? (if none, write "none")*
List any psychiatric medications prescribed in the past (if none, write "none")*
Have you had thoughts about not wanting to live or being better off dead?*

Yes, within the last TWO weeks.Yes, but it was OVER TWO weeks ago.Never
Have you ever had a plan to end your life?*

Yes, within the last TWO weeks.Yes, but it was OVER TWO weeks ago.Never
Have you ever harmed yourself (cutting, burning)?*

Yes, within the last TWO weeks.Yes, but it was OVER TWO weeks ago.Never
Have you ever attempted suicide?*

Yes, within the last TWO weeks.Yes, but it was OVER TWO weeks ago.Never
Have you ever been hospitalized for safety concerns (thoughts of harm to self or others).*

Yes, within the last TWO weeks.Yes, but it was OVER TWO weeks ago.Never
Please call 911 for any immediate safety concerns.
Family Psychiatric History
Please indicate if any of the following issues have been experienced within your immediate or extended family*

AlcoholismAddictionSchizophreniaAutism Spectrum DisordersADHDDepressionBipolar DisorderSuicide (threats/attempts/completed)AnxietyPhobiasPsychiatric hospitalizationsNone
If yes to any of the above, specify the relationship and if the relationship if maternal or paternal (if none, write "none")*
Substance Use History
Have you ever been treated for alcohol or drug abuse?*

YesNoUnsure
If yes, which substances? (if none, write "none")*
If yes, when were you last treated? (if never, write "never")*
How many days a week do you drink alcohol? (If you do not drink, write "none")*
days
How many drinks do you typically consume in one day? (If none, write "none")*
Do you consume marijuana in any form?*

YesNoUnsure
If yes, how often? (if never, write "never")*
Have you ever experimented with any street drugs?*

YesNoUnsure
If yes, what and when? (if never, write "never")*
How many caffeinated beverages do you drink in a day?*
drinks per day
Do you use nicotine?*

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
Date*

MonthDayYear
Date
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