Patient intake form

Are you filling this form on behalf of someone else (ex. your child)?


Please note, per clinic policy, if your "child" is over 18 years-old, they must be the person who completes the intake form.
If you are a social worker completing the intake form on behalf of your patient, please select "other;" however, our Intake Coordinator will need to confirm the intake process with the patient over the phone, per clinic policy.

What is your relationship with the patient?

If Other please specify your relationship:

Please provide your full name:

Please provide your email address:

Please provide your phone number:

Patient Name

Date of Birth

What is your current gender identity?

If you selected "another identity," please provide how you identify.

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

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

If you selected a "pronoun not listed," please write in your preferred pronoun.

Are you currently pregnant or trying to conceive?

Current mailing address

Phone number

Best times to call during the work week (Monday - Friday 8:30 am - 5 pm Eastern Standard Time)?

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.

Email address

Send Secure Preference

Email Security Policy
Email sent over the internet is not secure unless both parties are using an encryption technology. Without encryption, it is possible for other individuals (beyond the intended recipient of the email) to access and read the email and this could result in the unauthorized use or disclosure of your information. The Partners standard is to send email securely. If you prefer, we can send you "unencrypted" email that is not secure and could result in the unauthorized use or disclosure of your information. If you want to receive communications by unencrypted email despite these risks, Partners HealthCare will not be held responsible. While completing the intake form, please select your option on whether you prefer us to send emails securely (via send secure) or if you prefer to opt-out of send secure ("unencrypted" email). Your preference to receive unencrypted email will apply to: Research: Emails sent to you from research staff in the OCD and Related Disorders Program. If you wish to communicate with other research staff at Partners regarding additional studies, your preference will have to be documented with each research group. Clinical Care: Emails sent from clinicians and staff in the OCD and Related Disorders Program.

How did you hear about us?
Check all that apply

What is the name of your Insurance?

Is your current PCP (Primary Care Physician) at MGH?

Do you currently have a psychiatrist or psychologist at MGH?

Which disorder are you looking to receive treatment for? (Check all that apply):

If you have chosen more than one of the conditions from the checklist on question 12, please specify your main concern for which you are seeking treatment for?

What are your symptoms based on the disorder(s) you choose above?

How much time in a day do you experience these symptoms?

Would you describe the interference in your life as:

Please list any other psychiatric diagnosis.

Are you currently taking any psychiatric medication?

Have you been prescribed psychiatric medication in the past?

Are you currently in any form of therapy?

* Cognitive Behavior Therapy (CBT) - a type of therapy used to treat a wide range of psychological disorders, including obsessive-compulsive disorder, body dysmorphic disorder, depression, phobias, etc. The goal is to identify and modify distorted thoughts and replace negative and destructive behaviors with healthy behaviors.

Have you been in therapy in the past?

Have you had any previous psychiatric hospitalizations?

Have you had any alcohol in the past 3 months?

How frequently?

Have you used any type of street drugs or abused drugs in the past 3 months?

If 'Other' please specify

How frequently?

What type of treatment are you interested in receiving from the clinic? Please check all that apply.