The code block below illustrates how one might use # and // as comments in your logic and calculations.

This value you provided is not a number. Please try again.

This value you provided is not an integer. Please try again.

The value entered is not a valid Vanderbilt Medical Record Number (i.e. 4- to 9-digit number, excluding leading zeros). Please try again.

The value you provided must be within the suggested range

The value you provided is outside the suggested range

This value is admissible, but you may wish to double check it.

The value entered must be a time value in the following format HH:MM within the range 00:00-23:59 (e.g., 04:32 or 23:19).

This field must be a 5 or 9 digit U.S. ZIP Code (like 94043). Please re-enter it now.

This field must be a 10 digit U.S. phone number (like 415 555 1212). Please re-enter it now.

This field must be a valid email address (like joe@user.com). Please re-enter it now.

The value you provided could not be validated because it does not follow the expected format. Please try again.

Required format:

Cq8I4xcWTw9yAoWN8UCMxzVqRikSmKMpJdp2DukTWiAcwM8LsULDcT7nWc

Adult Intake Form

Returning?

A A A

Welcome! Please answer all the questions below so we can best address your concerns. Please note that completing an intake does not guarantee that you will be seen in our clinic. Please visit our FAQs on our website to learn more about our eligibility requirements and intake process.

For individuals under 18, please visit the Pediatric OCD and Tic Disorders Program page for their intake form.

The Center for OCD and Related Disorders (CORD) is not an Urgent Care Facility. If you are having thoughts of suicide or self-harm, please call 988 or text HOME to 741741 to receive support from a trained crisis counselor through a nationwide hotline. If this is an acute emergency requiring immediate medical attention or emergency personnel, please call 911 instead or go to the nearest emergency room.

Page 1 of 21

Thank you so much for taking the time to fill out this intake survey. Please feel free to use the "Save and Return Later" button if you need to complete this intake in more than one session, and it will save your progress. Pages 1-8 of this intake cover your background, current treatment team, and symptoms. Pages 9-18 each cover a specific OCRD diagnosis, and you will fill out the pages that apply to you. Finally, pages 19-21 cover questions about your psychiatric history. We ask these questions during our intake process to ensure that we are recommending the treatment options for you that are truly the best fit. Providing incomplete information may result in your intake taking longer to process.

Are you filling out this form on behalf of someone else?

Per clinic policy, if your "child" is over the age of 18 years old, they must be the person who completes the intake form either online or on the phone with a member of our team.

If you are a social worker or doctor who wants to refer a patient to the clinic, please do not complete the intake on behalf of the patient.

* must provide value

Yes

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What is your relationship with the patient?

* must provide value

Parent

Other

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If Other please specify your relationship:

* must provide value

Please provide your full name:

* must provide value

Please provide your email address:

* must provide value

Please provide your phone number:

* must provide value

Today's Date

* must provide value

M-D-Y

Patient's First Name:

* must provide value

Patient's Last Name:

* must provide value

Date of Birth

* must provide value

M-D-Y

Age calculation

View equation

DOB max

View equation

For individuals who are under the age of 18: Please visit the Pediatric OCD and Tic Disorders Program page for their intake form: https://mghocd.org/pediocdtic/.

What is your gender identity?

* must provide value

Man

Woman

Transgender man

Transgender women

Genderqueer, non-binary, or gender non-conforming

Questioning or unsure

Another identity; please, provide how you identify:

Prefer not to answer

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What sex were you assigned at birth on your original birth certificate?

* must provide value

Male

Female

Intersex

Choose not to disclose

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What are your pronouns? (e.g., how do you prefer others refer to you, such as 'she opened the door,' or 'he said hello')

What are your pronouns? (i.e., how should others refer to you such as "she opened the door" or "they said hello")

* must provide value

He / him / his / himself

She / her / hers / herself

They / them /their / theirs

Ze / hir / hirs / hirself

Another set of pronouns:

Prefer not to answer

Are you currently pregnant or trying to conceive?

* must provide value

Yes

Not applicable

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Do you have a disability (i.e., a physical or mental impairment that substantially limits one or more major life activities)?

Hearing

Vision (even when wearing glasses)

Cognitive

Mobility

Self-care or independent living

Other disability, specify:

Prefer not to answer

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Do you have a disability (i.e., a physical or mental impairment that substantially limits one or more major life activities)?

* must provide value

Hearing

Vision (even when wearing glasses)

Cognitive

Mobility

Self-care or independent living

Other disability, specify:

Prefer not to answer

Do you need an interpreter?

* must provide value

Yes

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Please provide what language

* must provide value

MGH Medical Record Number

Please call MGH Registration at 866-211-6588. Follow the prompts to be provided an MGH medical record number (MRN).

Please note, without providing an MRN we will not be able to process your intake form.

* must provide value

Current Address

If you live outside of Massachusetts, please visit the International OCD Foundation to search for providers in your area as we are not able to accept patients that live out of state.

* must provide value

Expand

Telephone Number

* must provide value

Is it okay to leave a voicemail on this line?

* must provide value

Yes

reset

E-mail Address

* must provide value

E-mail Security Preference:

Please review CORD's email security policy.

If you prefer to receive communications by unencrypted email despite the risks, your preference will apply to emails sent to you from the staff at this practice or department. To access encrypted emails, you will need to create an account. Encrypted emails can only be accessed using a computer, not a smartphone or tablet.

* must provide value

Use send secure

Use regular email (i.e., opt-out of send secure)

reset

What is your preferred contact method?

* must provide value

Phone

No preference

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What is the name of your Insurance?

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

* must provide value

You have selected an option that triggers this survey to end right now.

To save your responses and end the survey, click the 'End Survey' button below. If you have selected the wrong option by accident and/or wish to return to the survey, click the 'Return and Edit Response' button.