Timelines for services at DGA

INDIVIDUAL THERAPY SERVICES - updated February 2021

Due to the increased demand for services, we are experiencing longer than usual wait times for therapy services. For all therapy services, we will only be able to add new clients to the waiting list for therapy services. We are projecting for this wait to be approximately 5 to 7 months, in counting. If you are interested in being added to the waiting list for therapy, please submit an intake form for the intakes department to review your case. ***At this time, there are no available appointments for after 2pm on weekdays or for any time on Saturdays. Therapy appointments are available between 9am at 1pm, Monday through Friday, depending on the provider.***

MEDICATION MANAGEMENT SERVICES - updated February 2021

We do not have a waiting list for medication management services. However, please anticipate that available appointments will need to be booked several weeks out. Please read the intake guidelines regarding the required paperwork for medication management services. ***Our child psychiatrist (MD) is not accepting new clients, at this time. Medication management services can be scheduled with our available psychiatric nurse practitioners (PMHNP-BC).***

NEUROPSYCHOLOGICAL TESTING SERVICES - updated February 2021

Unfortunately, our neuropsychological testing has been put on hold, and we are not adding clients to our current waiting list. This is largely due to the fact that the assessments must be done in person, at least for now, and we do not have accommodations established for this during COVID19. We recommend reaching out to the agencies and facilities in your area to inquire about their status for neuropsychological testing.

FAMILY THERAPY AND COUPLES THERAPY SERVICES - updated February 2021

Due to the increased demand for services, we are experiencing longer than usual wait times for family and couples therapy services. For these services, we will only be able to add new clients to the waiting list for family therapy and couples therapy services. We project the wait time for these services to be approximately 6 to 8 months, in counting. If you are interested in being added to the waiting list for family and couples therapy, please submit an intake form for each participating member for the intakes department to review your case.

*Which services are you seeking at DGA? *

Individual therapy Medication management Couples therapy Family therapy Neuropsychological evaluation - updated February 2021 - Unfortunately, our neuropsychological testing has been put on hold, and we are not adding clients to our current waiting list. This is largely due to the fact that the assessments must be done in person, at least for now, and we do not have accommodations established for this during COVID19. We recommend reaching out to the agencies and facilities in your area to inquire about their status for neuropsychological testing. Other

*Please describe the reason(s) that you are seeking these services with DGA *

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Primary Care Physician

Location / Facility - Primary Care Physician

Phone - Primary Care Physician

Date last seen - Primary Care Physician

Date

Therapist

Location / Facility - Therapist

Phone - Therapist

Date last seen - Therapist

Date

Psychiatrist / Psychiatric Nurse Practitioner

Location / Facility - Psychiatrist or NP

Phone - Psychiatrist or NP

Date last seen - Psychiatrist or NP

Date

Medication #1 Name

Medication #1 Dose

Medication #1 Frequency

Medication #1 Prescriber

Medication #2 Name

Medication #2 Dose

Medication #2 Frequency

Medication #2 Prescriber

Medication #3 Name

Medication #3 Dose

Medication #3 Frequency

Medication #3 Prescriber

*Please indicate your (the client’s) responses for the following.

Date of last physical exam (approximately) *

Date

Allergies *

Major medical illnesses or conditions *

Major medical procedures *

Are you seeking services through an Employee Assistance Program (EAP) and / or for Workers' Compensation? *

Yes No

If yes, what is the insurance for your EAP?

History of psychiatric hospitalizatioins *

Yes No

If yes, when?

Psychiatric hospitalizations

Thoughts to hurt self *

Yes No

If yes, when was the last time?

Thoughts to hurt self

Thoughts to hurt someone else *

Yes No

If yes, when was the last time?

Thoughts to hurt someone else

Been the victim of a violent assault or sexual assault *

Yes No

If yes, when?

Victim of violent or sexual assault

Been the perpetrator of a violent assault or sexual assault *

Yes No

If yes, when?

Perpetrator of violent or sexual assault

Attempted suicide *

Yes No

If yes, when?

Attempted suicide

Self harm behaviors (e.g., cutting, burning, etc.) *

Yes No

If yes, when was the last time?

Self harm behaviors

History of attending a detox program for drugs or alcohol *

Yes No

If yes, when?

History of attending a detox program for drugs or alcohol

Abuse of illicit substances (e.g., heroin, cocaine, etc.) *

Yes No

If yes, what substance? When was the last date of use?

Abuse of illicit substances

Legal issues (e.g., arrests, probation, court ordered treatment, etc.) *

Yes No

*If yes, what type? - Legal issues

Legal issues

Involvement with the Department of Children and Families (DCF) *

Yes No

*If yes, when?

DCF involvement

Neuropsychological testing / evaluation *

Yes No

*If yes, when was the last time?

Neuropsychological testing

IEP and / or 504 in school *

Yes No

*If yes, when?

IEP or 504 in school

Please verify that you are human *

Intakes Department

Intakes Department

CHILD INTAKE FORM

Phone

Insurance information

Custody status of child

Services with Dana Group Associates

Timelines for services at DGA

Appointment availability

General Medical History

Medications

General Medical History Continued

Mental Health History

Guardian Authorization for treatment of a child

Guardian Authorization for treatment of a child