NBH Intake (under 18 years)

New Patient Intake Form

for Children ages 18 and under
Updated 7/7/22

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: 4-10 months

Approximate therapy wait time FOR NON-Pediatric Associates of Norwood and Franklin or Karuna Patients: 9-17 months

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 require you are in therapy at our practice or elsewhere if you are seeking medication manangement.

Approximate medication manangement wait time: 1 month

Telehealth ONLY: Our office is closed for in-person appointments. We do not have an opening date scheduled. If you would prefer to wait for in-person appointments, please let us know that when you are contacted to schedule.

Intake Appointment: Please note, 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.

Intakes will be contacted in the order in which they were received to schedule. If you have any additional questions, please contact Brittany at bditullio@norwoodbehavioralhealth.com.
Demographics
Child's Name *

First Name Last Name
Birth Sex *

Male Female Unknown
Date of Birth *

Month Day Year
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Primary Email Address *
Languages spoken other than English *

None
Gender Identity *
If additional gender category or other, please specify
Sexual Orientation *
If other, please specify
Race *
School Name *
Current Grade *
Primary Phone Number *

Area Code Phone Number
Type of Number *
Secondary Phone Number

Area Code Phone Number
Type of Number
Emergency Contact *

First Name Last Name
Emergency Contact Phone Number *

Area Code Phone Number
Type of Number *
Relationship to Child *
Parent/Guardian Information
Parent/Guardian #1 name *
Parent/Guardian #1 Marital Status *
Parent/Guardian #1 Relationship to Child *
Is Parent/Guardian #1 address the same as the patient? *

Yes No (if no, please enter address below)
Parent/Guardian #1 Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Parent/Guardian #2 name
Parent/Guardian #2 Marital Status
Parent/Guardian #2 Relationship to Child
Is Parent/Guardian #2's address same as the patient?

Yes No (if no, please enter address below)
Parent/Guardian #2 Address

Street Address

Street Address Line 2

City State / Province

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

Yes No
We are contracted with the following insurance plans:
- Blue Cross Blue Shield
- Cigna
- Harvard Pilgrim (Optum)
- Health Plans Inc.
- MassHealth ACO plans (i.e. Partners ACO, Boston Children's ACO)
- MassHealth Standard
- Tufts
- United (United Behavioral Health/Optum)
- BMC HealthNet (Beacon Health Strategies)
- Fallon (Beacon Health Strategies)
- AllWays Health Partners (Optum)
- UniCare (Beacon Health Options)
We DO NOT accept the following insurance plans:
- MassHealth Tufts Health Together
- Tufts Direct (Gold/Silver)
We are OUT-OF-NETWORK with the following plans:
- Aetna
- Tricare
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. By completing this registration form, you acknowledge this payment responsibility.
In-Network Insurance Plan *
Out-of-Network Insurance Plan
Subscriber's name *
Subscriber's D.O.B *

Month Day Year
Insurance Identification # *
Ins. phone # for mental health benefits

Area Code Phone Number
Is your health insurance plan either: a union plan, employer self-funded plan, or a trust plan?

Yes No
If answer to above question is Yes - please provide plan contact name and phone #
Do you have secondary insurance? *

Yes No
If yes, what type of secondary insurance do you have?
Secondary Subscriber's name
Subscriber's date of birth

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

Yes No
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 has your child had this problem? *
How is this problem affecting your child at home? In school? In peer relationships? *
If there has been a past evaluation, please bring a copy of the evaluation to the first visit. There is a release of information section at the end of this form.
Has this patient or other immediate family members been seen at Norwood Behavioral Health before? *

Yes No
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 Management Individual Therapy Neuropsychological Evaluation Family Therapy Parent Counseling
Medical History
Select your child's primary care doctor *
Is your child a patient at Karuna: Nutrition + Movement *

Yes No
If your child's doctor is not on the above list, please enter the group's name, doctor's name, address and phone number (if above, write "above") *
Do you give permission for ongoing updates to be provided to your PCP including but not limited to lab work and medication changes? *

Yes No
Preferred pharmacy (include street and town) *
Medical Drug Allergies (if none, write "none") *
Height *
inches
Weight *
lbs
Date of last known physical (if unknown, approximate date) *

Month Day Year
Date
List all current medications and supplements taken or needed (if none, write "none") *
Has your child ever had an EKG? *

Yes, normal Yes, abnormal No Unknown
Is your child adopted? *

Yes No
Age at adoption
Is your child a twin (or other multiple)? *

Yes No
If a twin, identical?

Identical twin Fraternal twin
How long was pregnancy? *
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 (if applicable)
years old
The following two questions apply to those assigned as female at birth that have begun their menstrual cycle.
Start date of last menstrual period (approximate if unsure)

Month Day Year
Date
Birth control method
Please indicate any illness or disease your child has had *

None Chronic fatigue Chronic pain Arthritis Seziures Concussion Migraines/Headaches Glaucoma Heart Disease High Chloesterol Asthma Sleep Apnea Gastrointestinal Issues Liver Disease Kidney Disease Thyroid Disease Cancer Frequent infections Bleeding Disorder
Average Number of Hours of Sleep Per Night *
Hours
Frequent or Waking Nightmares? *

Yes No
Any recent weight loss or gain? *

Yes No
Describe any unusual eating habits (picky eater, eating non-edible items, etc.) (If none, write "none") *
Social and Environmental History
With whom does the child currently live? *
If the child is not living with both biological parents, is either parent deceased?

Yes No
Are biological parents married? *

Yes No
Are biological parents divorced/separated? *

Yes No
If parents are not together, please describe custody agreement
NBH requires both parents to consent to services at our practice. Please indicate below that you understand and confirm that both parents agree to services. A signed statement may be requested by the therapist or psychiatrist at intake.
Please check this box to indicate you agree. *

Yes, both parents consent to psychiatry and/or psychotherapy services and will sign consent forms if requested by the clinician.
Any academic or social difficulties at school? (If none, write "none") *
Has your child ever repeated a grade? *

Yes No

Please indicate where you feel your child is performing academically *

	Below Grade Level	On Grade Level	Above Grade Level
Language Arts
Mathematics
Writing

Is your child currently in Special Education? *

Yes No
Is your child currently on a 504 plan? If yes, what is your child's diagnosis and the 504 Plan intervention? Do you feel it is effective? *
Date of Most Recent IEP

Month Day Year
Date
Does your child have difficulty with siblings? *
Has the child ever been placed or boarded away from the family? If so, describe (if no, write "no" *
Does your child have any past or current legal involvement? (If none, write "none") *
Does your child belong to any spiritual or religious group? (If none, write "none") *
Psychiatric History
Please list any psychiatric disorder your child has been diagnosed with in the past (if none, write "none") *
Has your child ever received outpatient treatment for a psychiatric disorder? *

Yes No Unsure
If so, when? (If none, write "none") *
Inpatient hospitalizations? *

Yes No Unsure
If so, when? (If none, write "none") *
List any psychiatric medications prescribed in the past (if none, write "none") *
Has your child had thoughts about not wanting to live or being better off dead? *

Yes, in the last TWO weeks. Yes, but it was OVER TWO weeks ago. Never
Has your child ever had a plan to end their life? *

Yes, in the last TWO weeks. Yes, but it was OVER TWO weeks ago. Never
Has you child ever harmed themselves (cutting, burning)? *

Yes, in the last TWO weeks. Yes, but it was OVER TWO weeks ago. Never
Has your child ever attempted suicide? *

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

Yes, in 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 you immediate or extended family: *

Alcoholism Addiction Schizophrenia Autism Spectrum Disorders ADHD Depression Bipolar Disorder Suicide (threats/attempts/completed) Anxiety Phobias Psychiatric hospitalizations None
If yes to any of the above, specify the relationship and if the relationship is maternal or paternal (if none, write "none") *
Substance Use History
Has your child ever been treated for alcohol drug abuse? *

Yes No Unsure
If yes, which substances? (If none, write "none") *
If yes, when was the child last treated? (if never, write "never") *
If your child drinks, how may days a week do they drink alcohol? (If they do not drink, write "none") *
Does your child consume marijuana in any form? *

Yes No Unsure
If yes, how often? (If never, write "never") *
Has your child ever experimented with street drugs? *

Yes No Unsure
If yes, what and when? (If never, write "never") *
How many caffeinated beverages does your child drink in a day? *
drinks per day
Does your child use nicotine? *

Yes No Unsure

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 Name Last Name
Relationship to Patient *
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