New Patient Intake Form
For Adults ages 18+
We are contracted with the following insurance plans:
If you are seeking psychiatric/medication management services, Dr. Robison accepts MEDICARE.
We DO NOT accept the following insurance plans:
We are OUT-OF-NETWORK with the following plans:
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.
Primary Care Doctor
Please indicate when you demonstrated each developmental milestone.
If you have any educational concerns, please bring copies of report cards to visit.
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.
Please indicate if you are currently exhibiting difficulty with any of the following.
By checking the box below, you are indicating you agree to and understand that all appointments must be cancelled within 24 hours. All missed appointments may result in a fee of $75.
Thank you for completing our intake form. We will review your information and contact you within 3 business days.
Please hit the "submit" button below to send your intake electronically, or you can print the form and mail it to our office: Norwood Behavioral Health, 100 Morse Street, Suite 220, Norwood, MA 02062