NBH Intake (under 18 years)

New Patient Intake Form

For Children under 18 years
Please note the following before completing this intake:

Waitlist: We currently are not scheduling new patients for therapy until early to mid-October. We are scheduling new patients for psychiatry at this time. 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: 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: Please keep in mind: school will be starting again in mid-September, which means our after school/evening slots will fill up very quickly in the next couple of weeks. Please be flexible, if possible, with the availability you indicate on the last page of this form.

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.

Psychiatry Intakes: If you are seeking psychiatric/medication management services, our providers are currently only accepting the following: Blue Cross Blue Shield, Blue Benefit Administrators, AllWays, Harvard Pilgrim, United, Cigna, Fallon, UniCare, BMCHP and Tufts.

Dr. Hamoda only accepts BCBS and Tufts and sees children, adolescents, and young adults.

Dr. Gerring is in process to credential with MBHP (MassHealth). Until credenting is processed, patients will be required to pay for visits out-of-pocket. Dr. Gerring sees patients of all ages.

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: *

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?