Patient Intake Form
Source of Referral
Name
*
First Name
Last Name
Preferred Name
Date of Birth
*
-
Month
-
Day
Year
Date
Gender
*
Please Select
Male
Female
Nonbinary
Transgender
Preferred Pronoun
Please Select
She/Her/Hers
He/Him/His
They/Them/Theirs
Legal Guardian Name
If the patient is under the age of 18.
Relationship to Patient
If the patient is under the age of 18.
Mailing Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email Address
*
example@example.com
Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Is it okay to leave a message?
*
Yes
No
Form of Payment
*
Aetna
AllWays Health Partners
Blue Cross Blue Shield
Cigna
Harvard Pilgrim
Optum
TriCare
United HealthCare
Private Pay
Tufts
Point32 Health
Medicare
Other
Insurance ID
*
To check for coverage of services
Please upload a photo of the front and back of your Insurance Card
Browse Files
Drag and drop files here
Choose a file
You may also Email these images to Info@newenglandpsychiatry.org, images required prior to registration.
Cancel
of
Insurance Group
Please list Group name and ID# if applicable
Start of Insurance Benefits
-
Month
-
Day
Year
Date
Last 4 Digits of SSN
*
For verification of insurance
Subscriber Name and Date of Birth
Full Name and relationship to patient
Type of Appointment
*
Psychiatric Evaluation (with/without medication management)
Psychological Evaluation (for ADD/ADHD done with Qbtech)
Psychotherapy (Massachusetts Only)
Vivitrol © Clinic (Rehab Completion)
Please be aware that the office requires a recent neuro/psychological evaluation (within the last 5 years) with a confirmed diagnosis of an attention deficit disorder in order to start Stimulants. We do offer Psychological testing. (We DO NOT offer a NEUROpsychological evaluation at this time).
Presenting Symptoms/Concerns
*
Discuss current presenting symptoms and/or mental health concerns.
Have you ever been diagnosed with Borderline Personality Disorder?
*
Please Select
Yes
No
Suspected
Have you ever been diagnosed with an Eating Disorder?
*
Please Select
Yes
No
Suspected
Have you ever been diagnosed with Bipolar Disorder?
*
Please Select
Yes
No
Suspected
Have you ever been diagnosed with Paranoia?
*
Please Select
Yes
No
Suspected
Have your ever been diagnosed with Schizophrenia?
*
Please Select
Yes
No
Suspected
Have you ever been diagnosed with Psychosis/Psychotic Break?
*
Please Select
Yes
No
Suspected
Hallucinations
*
Do you have a history of auditory, visual, and/or tactile hallucinations (hearing/seeing/feeling things that aren't really there)? If yes, please explain in detail first episode and most recent episode. Have the hallucinations ever told you to harm yourself or others? If yes, please explain.
Psychiatry Treatment History
*
Please list previous diagnosis and treatment history with past providers/therapists (inpatient, outpatient, residential), and outcomes.
Have you ever been prescribed, or has a prescriber considered, prescribing mood stabilizers (Lithium, Depakote, etc) or antipsychotics (Haldol, Zyprexa, ect.)?
*
Please Select
Yes
No
Medication History (Past and Current)
*
Please list Medication Name, Dose, Frequency, and Condition prescribed for. (Please include all prescriptions, over the counter medications, supplements, and vitamins including CBD and St. John's Wart.) (Please be aware of the office policies with certain medications. This can be found in "FAQs". )
Medication Allergies
*
Please list all Medication allergies along with reaction.
Preferred Pharmacy
*
Please provide preferred pharmacy name and address.
Last PCP visit/ Last lab work
Do you currently see a therapist?
*
If yes, please list name, facility, start of treatment, and frequency of sessions.
Current Living Situation
*
Please share details on your current living situation
Current Occupation
*
Please share your current Occupation or Job title.
Have you ever had an unpleasant experience with a provider?
*
If yes, please explain.
Any current or recent substance use?
*
Please Select
Yes
No
Have you ever been diagnosed with a Substance Use Disorder?
*
Please Select
Yes
No
Suspected
Substance Use History
*
Discuss substance use (including Caffeine, Tobacco/Nicotine, Alcohol, Cannabis, and Illicit substances). Please include history of use, as well as treatment history (detox, rehabilitation, halfway house, etc.).
Have you ever had thoughts of harming yourself?
*
Please Select
Yes
No
Have you ever had a suicide plan or attempt?
*
Please Select
Yes
No
Self Harm History
*
Please discuss self harm and/or suicide history, if applicable. Please include first episode and most recent episode information.
Homicidal Ideation/Violence History
*
Please discuss if you have had thoughts of harming others, if applicable. Please include first episode and most recent episode information.
History of Trauma
*
Please discuss if you had any history of trauma in your lifetime.
Has there ever been DCF involvement?
*
Please Select
Yes
No
Any current or history of legal issues/concerns?
*
Including, but not limited to: pending civil and/or criminal cases, DCF cases, and custody cases.
Are you currently on Disability/Medical Leave of Absence or looking to apply for Disability/Medical Leave of Absence?
*
If yes, please explain.
Any History of Academic Accommodations?
Please Select
Yes
No
Seeking Accommodations
Will you require any forms/letters to be completed by one of our providers?
*
Please Select
Yes
No
Including, but not limited to Workplace/School Accommodations form, Disability Forms, Military Clearance Forms, etc.
Medical History
*
Please list medical diagnoses and medications, if applicable (include as needed prescriptions, over the counter medications, vitamins, and supplements).
Goals for Treatment
*
Additional Pertinent Information
*
Please state if you have had any recent inpatient admissions for psychiatric conditions and the course of treatment.
Submit
Privacy Notice
*
Yes, I understand that any information sent from this website is encrypted via JotForm HIPAA Compliance . While unlikely, I accept that a breach of my privacy could occur when sending this information over the internet and/or when communicating by email and I am willing to accept that risk. I also understand that I have the option of calling the office for more Information.
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