NBH Intake (under 18 years)

Address *

Parent/Guardian Information
Parent/Guardian #1 name *
Parent/Guardian #2 name
Parent/Guardian #1 Marital Status *
Parent/Guardian #2 Marital Status
Parent/Guardian #1 Relationship to Child *
Parent/Guardian #2 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 *

Is Parent/Guardian #2's address same as the patient?

Yes No (if no, please enter address below)

Parent/Guardian #2 Address

Primary Care Doctor
Select your child's primary care doctor or person referring you to NBH *
If your child's doctor is not on the above list, please enter the pediatric group's name, the doctor's name, address and phone number *
Is your child on any medications or dietary supplements? *

Yes No
If yes, please indicate the medication, dosage, prescribing physician, and date of initial prescription
Preferred Pharmacy (Please include street & town) *
Medical Drug Allergies: *

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? *
Has your child been seen previously for psychological or psychiatric consultation? *

Yes No
If yes, name of professional
Dates of Service
Was an evaluation completed?
What type of evaluation?
Will you grant us permission to consult with this professional? *

Yes No
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 professional.
Has this person 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
Who referred you to NBH?