ADULT INTAKE FORM

Intakes Department

Phone. 781-429-7755 x1 Fax. 781-465-7995 intakes@dana-group.org
Please, take a moment to review the details about our waiting lists for services.

Thank you for considering Dana Group Associates!

The biggest factor that is helpful in finding an appointment quickly is the client’s flexibility on time for sessions as well as client’s openness to the gender of the clinician.

INDIVIDUAL THERAPY SERVICES - updated June 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 3 to 4 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.

MEDICATION MANAGEMENT SERVICES - updated June 2021

We do not have a waiting list for medication management services. Please read the intake guidelines regarding the required paperwork for medication management services.

NEUROPSYCHOLOGICAL TESTING SERVICES - updated June 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 June 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.

COVID-19 - updated June 2021

In response to COVID19, we are ONLY offering telehealth (VIDEO CHAT) services for both established clients and for new clients. As the situation is ever-evolving, we appreciate your patience as we navigate the safest ways to provide services to our clients. As such, we are preparing our staff and our clients for the changes that might occur in the coming days and weeks.

Thank you!

DGA Intakes Department

Intakes Department

Phone. 781-429-7755 x1 Fax. 781-465-7995 intakes@dana-group.org
ADULT INTAKE FORM
Thank you for your interest in Dana Group Associates!

The following documents are included:

•*Intake (REQUIRED)* - Please complete EACH of the items. If the items do not pertain to you, pleaseanswer “N/A.,” “none,” or put a dash through the answer box.

Once completed, you may submit the form through JotForm or email the forms to our secure email (intakes@dana-group.org). You may fax completed forms to our secure fax (781-465-7995). If you fax any documents, please follow up with the intakes department by email or by phone to confirm our receipt of the documents.

If you have any questions, please contact our intakes department by phone or by email.
*Please complete EACH item below for the person seeking services. *
Today's date *

Month Day Year
Date
Name *

First name Last name
DOB *
Age: *
Sex *for insurance verification* *

Female Male Other
Address *

Permanent Current
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Location preferred: *

Needham, MA Norwell, MA
Phone
Mobile *
Home
Work
*Email: *
example@example.com
Referral source:
How did you hear about DGA?
Insurance Information
Primary insurance name *
Member ID - primary insurance *
Group number (if applicable) - primary insurance
Policy holder *name / relationship* - primary insurance *
Secondary insurance name
Member ID - secondary insurance
Group number (if applicable) - secondary insurance
Policy holder *name / relationship* - secondary insurance

*Which services are you seeking at DGA? *

Individual therapy Medication management Family therapy Couples 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 *
Appointment availability

Please indicate the days and times that you are available for appointments.
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
General Medical History
Primary Care Physician
Location / Facility - Primary Care Physician
Phone - Primary Care Physician
Date last seen - Primary Care Physician

Month Day Year
Date
Therapist
Location / Facility - Therapist
Phone - Therapist
Date last seen - Therapist

Month Day Year
Date
Psychiatrist / Psychiatric Nurse Practitioner
Location / Facility - Psychiatrist / NP
Phone - Psychiatrist / NP
Date last seen - Psychiatrist / NP

Month Day Year
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

Intakes Department

Intakes Department

ADULT INTAKE FORM

Phone

Insurance Information

Appointment availability

General Medical History

General Medical History Continued...

Mental Health History