Please provide the following contact information:
Name (of person completing this form)
First name of person for whom you want services?
Last name
What is your relationship to this person? (e.g., self, mother, father, etc.)	Self  Parent  Guardian  Other
Date of Birth of potential client:	01/01/01
E-mail
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Home Phone
Work Phone
Cellular Phone
What clinician, if any, are you hoping to see?
Has this individual or any other immediate family member ever been seen at our practice?	Yes  No;     If yes,  who
Which office are you requesting services for?	First Choice Second Choice Third Choice Norwood Holliston Braintree Salem Boston   Norwood Holliston Braintree Salem Boston   Norwood Holliston Braintree Salem Boston
Marital Status (parent's marital status if completing intake for child)?	Not Married Married Divorced Separated                 Re-Married  Widowed
Other Spouse/Parent's Name
Other Parent's Address:
Other Parent's Phone Number:
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?    (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.)	Yes  No
Do you believe the other parent will consent to treatment?  (consent of both parents is required)	Yes  No
Is there currently, or do you anticipate a legal battle over custody, visitation, or anything related to the child?	Yes  No
Other services
Has the potential patients 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 had this year?
Is the potential patient currently seeing any other mental health provider?	Yes    No If yes, please provide the name(s) and telephone number of those clinicians:
If the potential patient is currently receiving psychotherapy how often are they being seen?	Weekly Every 2-3 weeks Monthly Less than Monthly
Has the potential patient ever been hospitalized for psychiatric reasons?	Yes    No
If yes, when was the last hospitalization?
Have you consulted any other professional about these problems?	Yes    No   If yes please list name and type of clinician (e.g. Dr. Jones, Psychiatrist or Mabel Smith, speech therapist)
Who is the potential client's primary care physician?
What is the primary care physician's telephone number?
Where are they located?
Who, if anybody, referred you to our practice or how did you find our practice?
Do we have your permission to thank the person who referred you?	Yes    No
Health Plan Information
Do you plan to use a health plan  to pay for our services?	Yes    No
If so, what type of health plan do you have?	HMO Blue -Massachusetts HMO Blue New England  Blue Cross Blue Shield PPO (Mass) Blue Cross-Indemnity (Mass) Blue-Cross-Non-Massachusetts  CIGNA  Aetna  Fallon Harvard Pilgrim/Pacificare Mass Behavioral Health Partnership Medicare Health Care Value Mngt.One Health Plan Private Health Care Systems Tufts Health Plan HMO  Tufts Health Plan-PPO  United Health Care/United Behavioral Health Other (write in name of plan)  (Required if you plan to use your insurance.)
Name of subscriber on insurance policy?	(Required if you plan to use your insurance.)	Subscriber's DOB 01/01/01 (Required if you plan to use your insurance.)
What is your Plan Identification Number?	(Required if you plan to use your insurance.)
What is your Plan Suffix number?
Health plan telephone number for mental health benefits?
If Union Plan/Self-funded plan, phone number for contact person:
Subscriber's Social Security Number	(Required for United Health.)
Services
Please briefly describe the nature of the problem you are seeking services for.
What type of services are you seeking? Check all that apply.	Unsure. Would like evaluation and recommendations for services. Medication Individual Psychotherapy Behavioral Medicine Family Therapy Group Therapy        Child Behavior Management Program               Adolescent Group Therapy (Dr. Richlin)          Social Skills Group          Parent Support Group: For parents of special               needs children 4-11 yo.  (Dr. Richlin) Forensic Services Neuropsychological Evaluation Psychological Evaluation Mediation Consultation Intelligence / Achievement Testing Developmental Evaluation Educational Therapy/Tutoring       Other, please specify:
If seeking medication, is patient in psychotherapy?	Yes    No
If potential patient is interested in seeing Drs. Lum or Herron for medication, can you come between 1:00 - 3:00 PM on a monthly basis?	Yes    No
Does the patient have any medical problems or symptoms?	Yes    No If yes, please list:
Do we have permission to leave a general message on your answering machine at home?	Yes    No
Can we leave a message at work as well?	Yes    No
When would you be able to come for services on a regular basis? (GIVE SPECIFIC DAYS & TIMES)	Matching a client with the appropriate clinician can be very hard and appointment times are very limited.  Providing as many options for SPECIFIC DAYS AND TIMES as possible will increase the chances that we will be able to meet your request.  Thank you in advance!
	PLEASE ALLOW 5 -7 BUSINESS DAYS FOR US TO COMPLETE INTAKE PROCESS & RESPOND.