NBH Intake (under 18 years)

New Patient Intake Form

For Children under 18 years
Updated 11/10/20

Please note the following before completing this intake:

Waitlist: We currently have a waitlist for afternoon/evening therapy sessions. We are able to schedule patients for morning/early afternoon appointments during the week.

We have also have a waitlist for psychiatry services. Dr. Hamoda is our only clinician accepting new patients. 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.

Please allow us 1-1.5 weeks for processing. 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.

Afternoon/Evening Appointments: We are FULL on afternoon/evening availabiity for therapy. If you only indicate afternoon/evening availability on your intake form, you will be added to our waitlist until we have matching availability open.

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
Child's Name *

First Name Last Name
Birth Sex *

Male Female Unknown
Date of Birth *

Month Day Year
Email Address *
Language(s) Spoken (other than English)
Gender Identity
If other, please specify
Sexual Orientation
If other, please specify
School *
Current Grade *
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
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 # *
Suffix #
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 #
Suffix #
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 #
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: *
Medical History
Is the child adopted? *

Yes No
Date of Adoption
Age of Child at Adoption
Is the child a twin (or other multiple)? *

Yes No
If a twin, identical?

Yes, identical twin No, fraternal twin
How long was pregnancy? *
Months
Any complications? If so, describe
Was the delivery through natural childbirth?

Yes, natural childbirth No, C-Section
Where was the delivery?

Hospital Home
Any complications during delivery? If so, describe
Please indicate any illness or disease your child has had *

Adverse Drug Reaction Allergies Asthma Broken Bones Dizziness/Fainting High/Low Blood Pressure Insertion/Removal of Tubes Chickenpox Measles Mumps Substance Abuse Arthritis Cancer Cerebral Palsy Diabetes Diphtheria Encephalitis Lead Exposure Meningitis Polio Tuberculosis None
If child has allergies please specify
If child has broken a bone please specify
Please indicate if your child has these frequent/recurring illnesses

Colds Gastrointestinal Problems Headaches High Fevers Influenza Migraine Headaches Pneumonia Seizures Sinusitis Sore Throats Strep Throat
Please indicate if your child has had any of these surgeries

Appendectomy Heart Surgery Tonsillectomy
Has your child ever been concussed? *

Yes No
Has your child ever been hospitalized over night? *

Yes No
Condition for Which Hospitalized, Date, and Length of Hospitalization
Does your child have any vision problems? *

Yes No
Does your child wear glasses or contact lenses? *

Yes, glasses Yes, contact lenses Yes, both glasses and contact lenses No Glasses/lenses prescribed but child does not wear
Does your child have hearing problems? *

Yes No
Does your child require hearing aids or other devices to amplify sounds? *

Yes No
Average Number of Hours of Sleep Per Night *
Hours
Frequent or Waking Nightmares? *

Yes No
Do you have concerns about your child's weight? *

Yes No
What percentage of food is home cooked? *
Percent
Describe any unusual eating habits (picky eater, eating non-edible items, etc.)
Family History
Please indicate if any of the following issues are currently being experienced within the immediate family (parents, siblings)

Marital difficulties Divorce/separation of parents Serious illness of parent, child, sibling Birth of new child Death in family Recent move Financial problems Single parent Job loss
If yes to "serious illness of parent, child, sibling" please specify
Please indicate which of the following concerns have been experienced in the immediate and/or extended family (parents, siblings, aunts, uncles, cousins, grandparents)

Autism Spectrum Disorders Learning Disabilities Mental Retardation Birth Defects Cancer Diabetes Attention Deficit Hyperactivity Disorder (ADHD) Alcoholism Drug Addiction Depression Bipolar Disorder Suicide (threats/attempts/completed) Anxiety Phobias Psychiatric Hospitalizations High Blood Pressure High Cholesterol Heart Disease
If yes to any of the above, specify the relationship to the child (specify maternal or paternal and relationship)
Background Information
Early Childhood

Please indicate when your child demonstrated each developmental milestone.
Child Walked *

< 12 months 12-24 months 24-36 months > 36 months Has Never Walked
Child Spoke Words *

< 12 months 12-24 months 24-36 months > 36 months Has Never Spoke Words
Child Spoke Sentences *

< 12 months 12-24 months 24-36 months > 36 months Has Never Spoke Sentences
Child First Trained for Urination *

< 12 months 12-36 months 3-5 years > 5 years Not Trained Yet
Child First Trained for Bowels *

< 12 months 12-36 months 3-5 years > 5 years Not Trained Yet
Since Initial Toilet Training *

Frequent wetting during the day Frequent wetting during the night Frequent soiling during the day Frequent soiling during the night No Issues
Puberty
Onset of puberty (breast development, menstruation, pubic hair, facial hair) *

< 10 years 10-12 years 12-14 years 14-16 years > 16 years Not Yet Developed
Educational

If you have any educational concerns, please bring copies of report cards to visit.
List all schools your child has attended, beginning with the most recent *
Has your child ever repeated a grade? *

Yes No
Reason for Repeated Grade
Has your child ever had problems in school? *

Yes No
If so, describe

Please indicate where you feel your child is performing academically *

Below Grade Level

On Grade Level

Above Grade Level

Language Arts

Mathematics

Writing

Does your child enjoy attending school? *

Yes No
If no, please explain
Has your child ever been referred for educational interventions, such as additional academic assistance, behavioral management plans, etc.? *

Yes No
If yes, please describe
Is your child currently on a 504 plan? *

Yes No
If yes, what is your child's diagnosis and the 504 Plan intervention?
Is your child currently in Special Education? *

Yes No
Date of Most Recent IEP

Month Day Year
Date
Educational Disability
Services Receiving
Do you feel the interventions (informal/504/Special Education are effective?

Yes No
If no, please explain
Family/Home Environment
Please list all those living in the child's home (relationship, age, occupation/school grade) *
Please list other persons closely involved with the child but not living in the child's home (e.g. older siblings, grandparents, sitters, teachers, etc.) Please frequency of visits. *
If child is not living with both biological parents, is either parent deceased?

Yes No
If so, please specify
Are biological parents married? *

Yes No
Are biological parents divorced/separated? *

Yes No
If so, when?
Which parent has custody?
How often does non-custodial parent visit?
How long have you lived at the current address? *
How often have you changed residences since the birth of the child? *
Does the child share a bedroom? *

Yes No
If so, with whom?
Does your child have difficulty with siblings? *

Yes No
If yes, please explain
Was the child ever placed or boarded away from the family? *

Yes No
If yes, indicate reason for placement, where, and with whom?
Has your child ever had difficulty or contact with legal authorities (Police, Juvenile Justice)? *

Yes No
If yes, please describe circumstances
Please describe any religious or cultural beliefs you would like incorporated into your child's treatment
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
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/is your child currently being seen 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/current 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?
Academic/Behavioral Checklist
Please indicate if your child is currently exhibiting difficulty with any of the following.
Reading - Basic Skills

Difficulty recognizing letters Difficulty reciting the alphabet Difficulty reading aloud (loses place or skips words) Dislikes reading/reluctant to read Reads slowly
Reading - Comprehension

Difficulty understanding the meaning of words Difficulty understanding the meaning of passages Difficulty identifying main idea Difficulty drawing conclusions Difficulty following written directions Difficulty understanding idioms or figurative language
Math Calculation

Difficulty identifying numerals Difficulty counting by rote Difficulty understanding basic arithmetic facts Difficulty completing problems involving basic calculation Difficulty completing problems involving fractions or decimals Difficulty completing problems involving geometric shapes Difficulty completing problems with more than one step
Math Reasoning

Difficulty understanding concepts related to size, sequence or quantity Difficulty identifying and using appropriate problem-solving strategies Difficulty solving word problems Difficulty completing problems involving estimation or prediction Difficulty understanding charts, tables, and graphs Difficulty generalizing math skills to other types of problems or tasks Difficulty understanding abstract mathematical concepts
Written Expression

Difficulty writing information dictated by others Difficulty with basic mechanics of writing Confused the order of words in sentences Writes in incomplete sentences Used simplistic language when writing Difficulty expressing ideas in writing Dislikes/avoids written tasks Poor handwriting (difficulty with letter formation, poor spacing between letters and words) Difficulty copying from blackboard
Oral Expression

Confuses or leaves out speech sounds Disfluency (unusual pauses or repetitions, frequent rephrasing, poor verbal organization) Grammatical problems (incorrect use of plurals, verb tense forms, pronouns, etc.) Limited vocabulary Word retrieval problems Problems with social language (initiating conversations, expressing thoughts and feelings, asking questions, etc.) Does not speak in class to teachers/students
Listening Comprehension

Difficulty following oral directions Frequently asks or repetition of oral instructions Misunderstands spoken word Easily distracted by noises or other sounds Exhibits short attention span during auditory tasks Confuses similar words Difficulty understanding sentences that are long or complex Cannot remember information presented verbally Cannot repeat information that was just spoken Appears disinterested in audio information (tapes, recordings, etc.) Demonstrates disruptive or off-task behaviors when required to listen Difficulty responding to questions within expected time limits
Social Behaviors

Misinterprets facial expressions or body language Overreacts to perceived insults Does not understand teasing, sarcasm, jokes Has few or no friends Displays attention-getting behaviors, acts like "class clown" Misinterprets tone of voice Isolated from others - few group or social interactions Withdrawn - does not make eye contact, seems introverted, does not participate in discussions
Emotional Behaviors

Excessive crying Overreacts to normal situations with excessive anger, fear, sadness, etc. Excessively afraid Excessively happy Gives up when challenged Appears depressed Appears excessively angry Does not talk
Other Behaviors

Excessively out of seat Refuses to comply with requests Frequently off-task Withdrawn Interrupts others when speaking Uses foul language Frequently fights with peers Engages in risky behaviors Associates with children that have been in trouble Difficulty focussing Poorly organized Experiences difficulty starting tasks Acts before thinking Can't sit still Experiences difficulty planning
Additional Comments
Person completing this form *
Relationship to client *

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

If you are requesting a specific provider please select here:
If you do not have a specific provider request leave blank.
Location: *
Services requested: *

Medication Management Individual Therapy Neuropsychological Evaluation Psychoeducational Evaluation Family Therapy Parent Counseling
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.
*

Yes, I agree to the cancellation policy. Yes, I agree to the intake policy.
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.
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.
Should be Empty: