• New Patient Intake Form

    College-Aged Adults 18-22

  • Updated 10/15/26

    This paragraph is updated with wait times and information each month. Please check back for updates. 

    We will review the availability you provided on your intake form. If we have an opening that matches your availablity, you will hear from us via email about 2 weeks after intake submission with an opening that fits the schedule you provided.

    If we do not currently have an opening that matches your availability, you will be added to our waitlist. You will be contacted as soon as we have an opening that matches the schedule you provided.

    If you have signed up for an ASAP Intake Evaluation, you will be added to the sign-up the week after intake submission.

    Please Note: if you are in college outside of Massachusetts, we will only be able to see you while you are in-state.

    Please email bditullio@norwoodbehavioralhealth.com with any questions.

     

    Therapy Waitlist (Individual, Parent, Family)

    We currently have a waitlist for therapy sessions. The longest waits are patients who: 

    (1) Would like to be seen ONLY in-person after 3pm Monday-Friday

    (2) Have very limited availabilty

    Flexibility to be seen via Telehealth (offered to patients age 10+) with schedule flexibility will shorten your wait for a weekly or biweekly slot.

    Current Wait Times

    Franklin Office: 3 months

    Norwood Office: 1 month

    Telehealth: 1 month

    "Wait times" are an estimate from the date of intake submission to when a recurring appointment time is offered.

    Please note: these wait times may increase or decrease due the number of spots that open each month. Please check back here for updates and waitlist information.

     

    ASAP Intake Evaluations

    Our waitlist is a result of our mostly school-aged population requiring after 3pm time slots. We are offering one-time intake evaluations to help shorten our wait times. There is more information on these visit types, as well as a place to indicate interest, later in this form.

    You will be added to our email blast for ASAP Intakes the following week after intake submission.

     

    Psychiatry (Medication Management) Waitlist

    We do strongly suggest you are in therapy at our practice or elsewhere if you are seeking medication management.

    Psychiatry services are currently only offered in the Norwood Office or virtually.

    We are currently not able to accept MGBHP Medicaid plans or MassHealth for medication management.

     

    Current Wait Times

    Norwood Office: 1 month

    Telehealth: 1 month

    "Wait times" are an estimate from the date of intake submission to when an intake appointment is offered.

    Please note: these wait times may increase or decrease due the number of spots that open each month. Please check back here for updates and waitlist information.

     

    Neurodevelopmental and Psychological Testing Waitlist

    We are now offering Neurodevelopmental and Psychological Testing with Dr. Joyce in the Norwood Office. If you are interested, please select testing as the one of the services you are looking for.

    Dr. Joyce is only accepting patients with Blue Cross Blue Shield, Blue Benefit Administrators, Harvard Pilgim, and Health Plans Inc. If you do not have one of these plans, the full testing panel starts at $3,200 (two payments of $1,600).

    Current Wait Time

    Norwood Office: 1 month

    "Wait times" are an estimate from the date of intake submission to when your testing agreement is sent to you to start the testing process.

    Please note: these wait times may increase or decrease due the number of spots that open each month. Please check back here for updates and waitlist information.

     

  • Demographics

  • Date of Birth*
     / /
  •  -
  •  -
  • Birth Sex*
  • Race*


  •  -

  • Parent/Guardian Information

    (if applicable)
  • Is Parent/Guardian #1 address the same as the client?
  • Is Parent/Guardian #2 address the same as the client?

  • Insurance Information

  • Do you anticipate using your health insurance to pay for services at NBH?*

  • We are CONTRACTED with the following insurance plans:

    Blue Cross Blue Shield, Blue Benefit Administrators
    Harvard Pilgrim
    Health Plans Inc. (All networks except BMC Select)
    MassHealth (must have Massachusetts Behavioral Health Partnership coverage)
    Mass General Brigham Health Plan (HMO/PPO and ACO) (Optum)
    United (Optum)
    UMR (Optum)
    Tufts
    ​
    We are OUT-OF-NETWORK or NOT ACCEPTING NEW PATIENTS with the following plans:

    Aetna
    Cigna
    ComPsych
    Fallon (Carelon)

    Health Plans Inc. BMC Select Network
    TriCare
    Tufts Health Together (MassHealth/Tufts product)
    Tufts Direct (Gold/Silver)
    Wellpoint (fka UniCare)
    WellSense (Carelon)
    ​
    If you have an OUT-OF-NETWORK/NOT ACCEPTED insurance plan, you will be required to pay for sessions out-of-pocket. We will provide you with rates when scheduled and are able to provide a receipt of payment to submit to your insurance company for reimbursement upon request

    Dr. Hamoda (Child and Adolescent Psychiatrist) is ONLY accepting clients with Blue Cross Blue Shield, Blue Benefit Administrators or direct payment.

    Dr. Joyce (Testing Psychologist) is ONLY accepting clients with Blue Cross Blue Shield, Blue Benefit Administrators, Harvard Pilgrim, Health Plans Inc. or direct payment for testing).

  • Subscriber's D.O.B*
     - -
  • Do you have secondary insurance?*
  • Subscriber's date of birth
     - -

  • 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 to allow us to communicate with your prior/current professional.

  • Have you or other immediate family members been seen at Norwood Behavioral Health before?*
  • When would you be able to come for service on a REGULAR basis (weekly/biweekly)? Please check all the apply.*
    Rows
  • Service(s) requested:*

  • For more information on different services, click HERE.

  • Preferred Visit Type*
  • Preferred Location*

  • Additional Psychotherapy Session Options:

    Our waitlist is a result of our school-aged population requiring after 3pm time slots. We have developed two additional treatment options to help shorten our wait times.

    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.

    ASAP Intake Evaluation: We have immediate openings for Intake Evaluations. These sessions are 60-minutes long and are used to establish goals, ask questions, identify referrals to other specialities, and collaborate on short-term solutions. Intake appointments are available during the day (M-F, 9-2pm) and are an opportunity to receive an assessment as soon as possible. After Intake, you would return to the waitlist until a weekly or biweekly therapy slot opened with one of our clinicians that matches your schedule availability. Intakes can be seen in-person or via Telehealth.

  • I am interested in Short-Term Psychotherapy.*
  • I am interested in an ASAP Intake Evaluation.*

  • Medical History

  • Are you a patient at Karuna: Nutrition + Movement?*
  • Do you give permission for ongoing updates to be provided to your PCP?*
  • Date of last physical exam (if unknown, approximate date)*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Have you ever had an EKG?*
  • Were you adopted?*
  • Are you a twin (or other multiple)?*
  • If a twin, identical?

  • The following few questions apply to those assigned as female at birth:

  • Start date of last menstrual period (approximate if unsure)
     - -
    2 digit month, 2 digit day, 4 digit year
  • Are you currently pregnant or think you might be pregnant?
  • Are you planning to get pregnant in the near future?
  • Have you had a miscarriage?
  • Please indicated illness or disease you have had*

  • Frequent or Waking Nightmares?*
  • Any recent weight loss or gain?*

  • Social and Environmental History

  • Are you in a relationship?*

  • Psychiatric History

  • Have you ever received outpatient treatment for a psychiatric disorder?*
  • Inpatient hospitalizations?*
  • Have you had thoughts about not wanting to live or being better off dead?*

  • Have you ever had a plan to end your life?*

  • Have you ever harmed yourself (cutting, burning)?*

  • Have you ever attempted suicide?*
  • Have you ever been hospitalized for safety concerns (thoughts of harm to self or others).*

  • Please call 911 for any immediate safety concerns.

  • Family Psychiatric History

  • Please indicate if any of the following issues have been experienced within your immediate or extended family*

  • Substance Use History

  • Have you ever been treated for alcohol or drug abuse?*
  • Do you consume marijuana in any form?*
  • Have you ever experimented with any street drugs?*
  • Do you use nicotine?*

  • Release of Information

    Completing this ROI section allows us to communicate with your Primary Care Physician and (2) additional clinicians, if applicable. If you have additional clinicians to release to, you can complete the Release of Information form on our website after your intake appointment.
  • I DO authorize Norwood Behavioral Health to contact my Primary Care Physician*
  •  -
  • For dates starting on:
     - -
    2 digit month, 2 digit day, 4 digit year
  • I DO authorize Norwood Behavioral Health to contact the below clinician/ organization*
  • Provider Type

  •  -
  • For dates starting on:
     - -
    2 digit month, 2 digit day, 4 digit year
  • I DO authorize Norwood Behavioral Health to contact the below clinician/ organization*
  • Provider Type

  •  -
  • For dates starting on:
     - -
    2 digit month, 2 digit day, 4 digit year

  • If you have more providers to release to, your clinician can provide a Release of Information form at your first session.

     

    Please read and sign below.

    Information released includes but is not limited to: diagnosis, prognosis, treatment data, initial interview, treatment summaries, discharge summary, psychological asssessment or other information.

    I understand that my records are protected under federal and Massachusetts laws and cannot be disclosed without my written consent except as othewise specified by these laws. Furthermore, I understand that if my records involve alcohol or drug abuse they are also prohibited under the Federal Reg. 42CFR, confidentiality of alcohol and drug abuse.

    I have carefully read and understand the above statements and do herein consent to disclose the above information, including alochol and drug abuse records, if relevant, to those persons/agencies named above.

    I further release Norwood Behavioral Health from any liability arising form the release of this information to such persons/agencies, provided that said release of information is done substantially in accordanc with applicable laws. I understand that I may revoke my consent at any time. This revocation will only affect future disclosure or release information.

  • Date*
     - -
    2 digit month, 2 digit day, 4 digit year

  • 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 required 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.

  • Important Information While Awaiting Your First Appointment

  • Thank you for your interest in receiving care at Norwood Behavioral Health (NBH). We understand that reaching out for behavioral health services is an important step, and we appreciate the opportunity to assist you or your family.

    Please review the following information carefully while awaiting your first appointment.

    Your Care While Waiting for an Appointment

    Norwood Behavioral Health is an outpatient behavioral health practice and does not provide emergency or crisis intervention services.

    Submitting intake paperwork, requesting an appointment, or being placed on our waiting list does not establish an ongoing patient-provider treatment relationship with NBH. Your clinical care with our practice begins following your initial appointment and evaluation by an NBH clinician.

    Until that time, we encourage you to continue working with your current healthcare providers, including your primary care provider, pediatrician, therapist, psychiatrist, or other treating professionals, as appropriate.

    Questions About Suicide or Self-Harm

    Questions on this intake form about suicide or self-harm are intended to gather information for the intake process. Your answers do not replace a clinical evaluation or, by themselves, determine the patient’s level of risk. Completing this form is not a way to request emergency assistance. If you or your child needs urgent help, please use the resources below rather than waiting for an appointment or a response from NBH.

    When to Seek Help

    Behavioral health symptoms can change, sometimes unexpectedly. Please do not wait for your scheduled appointment if you or your child is experiencing worsening symptoms, increased emotional distress, or concerns about safety.

    Examples of situations that may require prompt attention include:

    • Thoughts of suicide, self-harm, or harming another person.
    • Feeling unsafe or unable to maintain your own safety or your child’s safety.
    • Significant changes in behavior, mood, or emotional functioning.
    • Severe anxiety, depression, panic, or emotional distress that interferes with daily functioning.
    • Confusion, hallucinations, or behavior that raises concerns about someone’s immediate safety.
    • Any other behavioral health concern that you feel requires attention before your scheduled appointment.


    Emergency and Crisis Resources

    If you or someone else is in immediate danger, has a medical emergency, or cannot remain safe, call 911 or go to the nearest emergency department.

    For urgent behavioral health concerns, the following resources are available:

    988 Suicide & Crisis Lifeline

    Call 988 or text 988 for crisis support related to suicidal thoughts or emotional distress.

    Massachusetts Behavioral Health Help Line (BHHL)

    Call or text 833-773-2445 for behavioral health support, crisis assistance, and help connecting with services. Available 24 hours a day, 7 days a week.

    Riverside Community Care – Behavioral Health Crisis Services

    Riverside provides behavioral health crisis evaluation and support services in many Massachusetts communities. Services may include mobile crisis intervention, crisis assessment, and assistance connecting with appropriate care.

    For assistance locating crisis services in your community, call the Massachusetts Behavioral Health Help Line at 833-773-2445.

    While Awaiting Your Appointment

    If your needs become more urgent, please seek assistance through your current healthcare provider, a behavioral health urgent care service, or one of the crisis resources listed above.

    NBH’s administrative and scheduling staff cannot provide emergency clinical assessment or crisis intervention. Intake forms and messages left with our office should not be used to request emergency assistance.

    Patient/Parent/Guardian Acknowledgment

    By signing below, I acknowledge that:

    • I understand Norwood Behavioral Health is an outpatient practice and does not provide emergency or crisis services.
    • I understand that submitting intake paperwork, requesting an appointment, or being placed on a waiting list does not establish an ongoing treatment relationship with an NBH clinician.
    • I understand that answers to questions about suicide or self-harm are collected for intake purposes only. The information provided on this form does not replace a clinical evaluation or, by itself, determine the patient’s level of risk.
    • I understand that completing this intake form or leaving a message with NBH is not a way to request emergency assistance.
      I have been provided with information about when and where to seek urgent or emergency behavioral health assistance.
    • I understand that I should not delay seeking necessary medical or behavioral health care while awaiting my first appointment at NBH.

  • 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.

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