• New Patient Intake Form

    For Children under 18 years

  • Updated 3/10/21

    Please note the following before completing this intake:

    Waitlist: We currently have a waitlist for both therapy and psychiatry sessions.

    At this time, Dr. Hamoda is our only psychiatrist. Dr. Hamoda is only contracted with BCBS and Tufts. We do require you are in therapy at our practice or elsewhere if you are seeking medication manangement.

    Intakes will be contacted in the order in which they were received to schedule. If you have an urgent issue, please contact Brittany at bditullio@norwoodbehavioralhealth.com.

    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.

    For Additional Questions: Email Brittany at bditullio@norwoodbehavioralhealth.com

  • Child Demographics

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  • Parent/Guardian Information

  • Insurance Information

  • 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.

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  • Primary Care Doctor

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    Medical History




  • Family History



  • Background Information

  • Early Childhood

    Please indicate when your child demonstrated each developmental milestone.

  • Puberty

  • Educational

    If you have any educational concerns, please bring copies of report cards to visit.

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  • Family/Home Environment

  • 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 call 911 for any immediate safety concerns

  • Referral Information

  • If there has been a past evaluation, please bring a copy of the evaluation to the first visit. We will have you complete a consent form in the office to allow us to communicate with your prior/current professional.

  • Academic/Behavioral Checklist

  • Please indicate if your child is currently exhibiting difficulty with any of the following.

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  • By checking the box 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.

    By checking 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.

  • Consent to Treat/Informed Consent

    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.

    You may address a problem or resolve a complaint by contacting the Clinical Director below.

    Norwood Behavioral Health

    Dr. Joseph Schembri, Clinical Director

    100 Morse Street

    Suite 220

    Norwood, MA 02062

    Please note: Dr. Joseph Schembri is our Clinical Director. He is responsible for supervising all clinicians. Dr. Schembri will review all patient intake information and/or may consult with our clinicians regarding your care. 

    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.

  • Clear
  • 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.

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