Patient Intake Form Step 2

Patient Intake Form Step 2
Is it OK to leave a voicemail on your phone?*

YesNo
Your Date of Birth

MonthDayYear
Date
Legal Guardian Name
If the patient is under the age of 18.
Relationship to Patient
If the patient is under the age of 18.
Gender*
Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Form of Payment*

AetnaAllWays Health PartnersBlue Cross Blue ShieldCignaHarvard PilgrimOptumTriCareUnited HealthCarePrivate Pay
Insurance ID*
To check for coverage of services PLEASE ALSO SEND A COPY OF YOUR INSURANCE CARD (BACK AND FRONT) TO INFO@NEWENGLANDPSYCHIATRY.ORG
Insurance Group
Please list Group name and ID# if applicable
Start of Insurance Benefits*

MonthDayYear
Date
Last 4 Digits of SSN*
For verification of insurance
Subscriber Name
Full Name and relationship to patient
Type of Appointment*

Psychiatric Evaluation (with/without medication management)Psychological Evaluation (for ADD/ADHD done with Qbtech)
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 at an out of pocket fee of $150. (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?*
Have you ever been diagnosed with an Eating Disorder?*
Have you ever been diagnosed with Bipolar Disorder?*
Have you ever been diagnosed with Paranoia?*
Have your ever been diagnosed with Schizophrenia?*
Have you ever been diagnosed with Psychosis/Psychotic Break?*
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.)?*
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". )
Do you currently see a therapist?*
If yes, please list name, facility, start of treatment, and frequency of sessions.
Have you ever had an unpleasant experience with a provider?*
If yes, please explain.
Any current or recent substance use?*
Have you ever been diagnosed with a Substance Use Disorder?*
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?*
Have you ever had a suicide plan or attempt?*
Self Harm History*
Please discuss self harm and/or suicide history, if applicable. Please include first episode and most recent episode information.
Homicidal Ideation*
Please discuss if you have had thoughts of harming others, if applicable. Please include first episode and most recent episode information.
Violence History*
Please discuss if you have had thoughts of harming others, if applicable. Please include first episode and most recent episode information.
Has there ever been DCF involvement?*
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.
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.
Please Confirm Your Name*

First NameLast Name
Preferred Name
Source of Referral*
Privacy Notice*

Yes, I understand that any information sent from this website is not encrypted and therefore my privacy cannot be guaranteed while it travels on the internet. 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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