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h7PHWAMdjQY2fthnAZyQZjxt4d3ah8hwed7UWNnzwz

Pediatric OCD and Tic Disorders Clinical Intake

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Please read these instructions before filling out this intake form!

Hi! Welcome to the Pediatric Psychiatry OCD and Tic Disorders Program clinical intake form.

Before filling out the form, please call MGH Registration at 866-211-6588 to obtain a Medical Record Number (MRN). We cannot complete the intake process without an MRN.

Please answer all the questions below so that we can determine how to best address your concerns.

Someone will be in contact with you from our clinic as soon as we are able to review the form, typically within 2-3 weeks of submission.

IMPORTANT:

Please note that we cannot treat PANDAS (Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal Infections) or PANS (Pediatric Acute-onset Neuropsychiatric Syndrome) in our clinic

For PANDAS/PANS, please contact Mary Spencer at the Pediatric Neuropsychiatry and Immunology Program at 617-724-0198 or mspencer5@partners.org.

This program does not currently offer behavioral talk therapy.

Patients must reside in one of the following New England States: MA, NH, VT, CT, RI and ME.

Please note that we do not take all insurance plans so please be thorough with the full name of your insurance company and plan.

If you have any questions, you can send an email to MGHPediOCDTics@partners.org!

Thank you!

MGH Medical Record Number

Please call MGH Registration at 866-211-6588. You will be given an MGH medical record number (MRN), which you will need in order to be seen in the OCD and Related Disorders Program. Please note, without an MRN we will not be able to process your request and you will not be able to be seen in the clinic

* must provide value

Which health insurance policy would you want to have your appointments billed to? Please indicate whether this is a PPO or HMO policy and whether it is in state or out of state.

If your behavioral health benefits are covered through a different provider, please note that as well.

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Today's date:

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M-D-Y

What are you hoping to achieve by being seen in our program? Choose all that apply.

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I hope to find out about, consider, and possibly try medication options for my child.

I hope to have a one-time consult for a diagnosis or to get a second opinion about what my child experiences.

I would like to speak to a medical professional about what my child experiences and learn about possible treatment and resources.

Other

This program does not provide therapy like cognitive behavioral therapy (CBT), habit reversal therapy (HRT), exposure & response prevention (ERP), or comprehensive behavioral intervention for tics (CBIT) at this time. Depending on your child’s needs, we can recommend therapists and other resources in the community after an initial consult.

Other (please explain):

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Patient's full legal name (including all surnames):

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Patient's preferred, current, or chosen name AND/OR nickname (not required if same as legal name):

Patient's pronouns:

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Patient's date of birth:

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M-D-Y

Patient's age:

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Full name(s) of all parent(s)/guardian(s):

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Home address:

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What is the best email address for us to reach you?

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Information on E-mail security

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Pediatric OCD and Tic Disorders Clinical Intake

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