NBH Intake (under 18 years)

New Patient Intake Form

for children ages 18 and under
Updated 12/29/22

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: 1-4 months

Approximate therapy wait time FOR NON-Pediatric Associates of Norwood and Franklin or Karuna Patients: 1-4 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 strongly suggest you are in therapy at our practice or elsewhere if you are seeking medication management.

Approximate medication management wait time: 1 month

Telehealth: Most of our staff are seeing all patients through telehealth or a combination of in-person and telehealth sessions. If you would prefer all 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 Legal Name*

First NameLast Name
Birth Sex*

MaleFemaleUnknown
Date of Birth*

MonthDayYear
Preferred Name
Pronouns*
Address*

Street Address

Street Address Line 2

CityState / 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*

UnknownChoose to not disclose
Ethnicity*
Religious Affliation
Primary Phone Number*

Area CodePhone Number
Type of Number*
Secondary Phone Number

Area CodePhone Number
Type of Number
Emergency Contact*

First NameLast Name
Emergency Contact Phone Number*

Area CodePhone Number
Type of Number*
Relationship to Child*
School Name*
Current Grade*
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?*

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

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
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?

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

Street Address

Street Address Line 2

CityState / Province

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

YesNo
We are CONTRACTED with the following insurance plans:

Blue Cross Blue Shield
Cigna
Massachusetts Behavioral Partnership (MassHealth)
Optum Behavioral Health (Mass General Brigham Health Plan (f.k.a. AllWays), Harvard Pilgrim and United)
Tufts

We are OUT-OF-NETWORK with the following insurance plans:

Aetna
BMC Healthnet
ComPsych
Fallon
TriCare
Tufts Health Together (MassHealth/Tufts product)
Tufts Direct (Gold/Silver)
UniCare

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.

Dr. Hamoda (Child and Adolescent Psychiatrist) is ONLY contracted with Blue Cross Blue Shield.
In-Network Insurance Plan*
Out-of-Network Insurance Plan
Subscriber's name*
Subscriber's D.O.B*

MonthDayYear
Insurance Identification # *
Ins. phone # for mental health benefits

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

YesNo
If answer to above question is Yes - please provide plan contact name and phone #
Do you have secondary insurance?*

YesNo
If yes, what type of secondary insurance do you have?
Secondary Subscriber's name
Subscriber's date of birth

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

YesNo
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?*

YesNo
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 ManagementIndividual TherapyFamily TherapyParent Counseling
Preferred Visit Type*

In-PersonTelehealth (MA residents only)No Preference
Preferred In-Person Location*

NorwoodFranklinNo PreferenceI only want to meet via Telehealth.
Short-Term Psychotherapy: In light of our waitlist, we are opening slots for short-term psychotherapy. Short-term treatment is typically more goal-oriented than long-term therapy and tends to focus on specific challenges. Short-term therapy tends to last from about 1-10 sessions, or 1-3 months. The therapist would assess your needs at the first session and determine if you would be a candidate for short-term therapy.
I am interested in short-term psychotherapy*

YesNoI am not looking for psychotherapy (referral is for testing or medication management).
Medical History
Select your child's primary care doctor*
Is your child a patient at Karuna: Nutrition + Movement*

YesNo
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?*

YesNo
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)*

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

Yes, normalYes, abnormalNoUnknown
Is your child adopted?*

YesNo
Age at adoption
Is your child a twin (or other multiple)?*

YesNo
If a twin, identical?

Identical twinFraternal 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)

MonthDayYear
Date
Birth control method
Please indicate any illness or disease your child has had*

NoneChronic fatigueChronic painArthritisSeziuresConcussionMigraines/HeadachesGlaucomaHeart DiseaseHigh ChloesterolAsthmaSleep ApneaGastrointestinal IssuesLiver DiseaseKidney DiseaseThyroid DiseaseCancerFrequent infectionsBleeding Disorder
Average Number of Hours of Sleep Per Night*
Hours
Frequent or Waking Nightmares?*

YesNo
Any recent weight loss or gain?*

YesNo
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?

YesNo
Are biological parents married?*

YesNo
Are biological parents divorced/separated?*

YesNo
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?*

YesNo

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?*

YesNo
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

MonthDayYear
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?*

YesNoUnsure
If so, when? (If none, write "none")*
Inpatient hospitalizations?*

YesNoUnsure
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:*

AlcoholismAddictionSchizophreniaAutism Spectrum DisordersADHDDepressionBipolar DisorderSuicide (threats/attempts/completed)AnxietyPhobiasPsychiatric hospitalizationsNone
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?*

YesNoUnsure
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?*

YesNoUnsure
If yes, how often? (If never, write "never")*
Has your child ever experimented with street drugs?*

YesNoUnsure
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?*

YesNoUnsure

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 NameLast 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