Intake
Form (MAIL or FAX) Click here to submit via web form
Your Name : ______________________________________________Address: _________________________________________________
__________________________________________________________
E-Mail: __________________________________________________
Home Phone: (_____) __________________
Work Phone: (_____) __________________
Cell Phone: (_____) __________________
Today's Date: ____ / ____
/ ____
• What clinician, if
any, are you hoping to see?
__________________________________________________________
• Who are you seeking
services for?
__________________________________________________________
• What is your relationship
to this person?
__________________________________________________________
• Date of Birth of potential
client: ____ / ____ / ____
• Marital Status
(parent's marital status if completing intake for child)?
____ Single _____ Married ____ Separated ____ Divorced ____ Re-Married
• Spouse/Parent's Name:
_________________________________________________________
• If marital status is other than married, please list other parent's:
Name: ___________________________________ Phone #:
(______)________-______________
Address:_________________________________________________________________________
• If you are a parent
seeking treatment or evaluation for
a child and are divorced
or separated from the child's other
parent, please answer the following questions:
* Do you have sole legal
custody? ( )Yes ( ) No
(Legal custody is not the same as Physical Custody. Sole
legal
custody means the
parent legally has complete control
to make
decisions for the child.)
* Do you believe the other parent will consent to treatment? ( )Yes (
)No
(consent of both parents is required)
* Is there currently, or do you anticipate a legal battle over custody,
visitation,
or anything related to
the child? ( )Yes ( )No
• Who is the potential
client's primary care physician?
_________________________________ Telephone Number: (____)
________-_____________
• Where are they located?
__________________________________________________________
• Who, if anybody, referred
you to our practice? _____________________________________
• Do we have your permission to thank the person who
referred you? ( )Yes ( )No
• Do you plan to use
your health insurance to pay for our
services?
( ) Yes
( ) No
• If so, what type of health insurance do you have?_______________________________________
• Subscriber's name?
__________________________________________________________
• Subscriber's Date of Birth: ____ / ____ / ____
• Insurance Identification number? ________________________________ Suffix
#: __________
• Subscriber's Social Security Number
(required for United Health
Plans) ________________________________
• Insurance telephone
number for mental health benefits? (_____) ____________________
• Has the potential patient used any mental health insurance benefits this
calendar year? ( ) Yes ( ) No
• If so, how many visits with a mental health clinician do you think you have
used this year? ______________________________
• Has the potential patient ever been hospitalized for psychiatric reasons?(
)Yes( )No
• If yes, when was the last hospitalization? _____________________________
• Please briefly describe
the nature of the problem you are
seeking services for.
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
• List all medical symptoms or problems the patient has:
• List the names and
professions of any other professionals you have consulted about
these problems:
• What type of services
are you seeking? Check all
that apply.
( ) Unsure. Would like evaluation and recommendations
for services.
( ) Medication
( ) Individual Psychotherapy
( ) Family Therapy
( ) Group Therapy, Which group? _________________________________
( ) Forensic Services
( ) Neuropsychological Evaluation
( ) Psychological Evaluation
( ) Mediation
( ) Consultation
( ) Developmental Evaluation
( ) Educational Therapy/Tutoring
( ) Other, please specify: __________________________________________________________
• If seeking medication, is patient in psychotherapy? ( )Yes
( )No
• If Yes, how often seen on average?
__weekly __every other week __monthly __less than monthly
• Therapist Name: __________________________ Therapist Phone
#:(_____)____________________
• If potential patient is interested in seeing Dr. Lum, can you come
between 1:00 - 3:00 PM on a monthly basis? ( ) Yes ( ) No
|
Which office are you
requesting services for? |
|
• Do we have permission
to leave a general message on your
answering machine at
home? At Work?
( ) Yes
( ) Yes
( ) No
( ) No
• When would you be able
for services on a regular basis?
Obtaining services after
3 P.M. on weekdays are extremely
difficult given the high demand. Please be
sure to
check
all that apply:
( ) Anytime
| ( ) 8-12 |
( ) 12-2
P.M. |
( ) 3-6 P.M. |
( ) after
6 P.M. |
| ( ) 8-12 |
( ) 12-2
P.M. |
( ) 3-6 P.M. |
( ) after
6 P.M. |
| ( ) 8-12 |
( ) 12-2
P.M. |
( ) 3-6 P.M. |
( ) after
6 P.M. |
| ( ) 8-12 |
( ) 12-2
P.M. |
( ) 3-6 P.M. |
( ) after
6 P.M. |
| ( ) 8-12 |
( ) 12-2
P.M. |
( ) 3-6 P.M. |
( ) after
6 P.M. |
| ( ) 8-12 |
( ) 12-2
P.M. |
( ) 3-6 P.M. |
( ) after
6 P.M. |
Please allow
5 - 7 business days to complete intake process.
Please print out this form
and fax it us at 781-551-3396,
or mail it to:
Child & Family Psychological Services
89 Access Road, Unit 24
Norwood, MA 02062
|
