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/^((0?[1-9])|([1-8][0-9])|(9[0-8]))[0-9]{3}$/

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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 guarentee that you will be seen in our clinic. You can visit our FAQs on our website to learn more information about our intake process.

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

The Center for OCD and Related Disorders (CORD) in 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

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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 of on the phone with the intake coordinator.

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. The patient will need to reach out to our intake coordinator directly.

* must provide value

Yes

No

What is your relationship with the patient?

* must provide value

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 Full Name

* must provide value

Date of Birth

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/

* must provide value

What is your current gender identity?

What is your 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 others refer to you, such as 'she opened the door,' or 'he said hello')

If you selected a "another set of pronouns" please write in your preferred pronoun.

Are you currently pregnant or trying to conceive?

* must provide value

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

Other disability; please specify:

Do you need an interpreter?

Yes

No

Please provide what language

What is your MGH Medical Record Number (MRN)?

If you do not know your MRN, please call MGH Registration at 866-211-6588

* must provide value

Current Address

If you live outside of Massachusetts, please visit the International OCD Foundation to search for providers in your area

* must provide value

Expand

Telephone Number

* must provide value

Is it okay to leave a voicemail on this line?

* must provide value

Yes

No

E-mail Address

* must provide value

E-mail Security Preference:

Information on E-mail Security

* must provide value

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

How did you hear about us?
Check all that apply

* must provide value

Online

Flyer

Print Ad

HealthCare provider (PCP, therapist, psychiatrist, social worker, counselor, etc)

MBTA (public transportation, the T)

Other

I am a MGH employee

If other please specify

* must provide value

If a HealthCare provider, please specify.

* must provide value

Please provide the name of the referring MGH doctor

* must provide value

Department Name

* must provide value

Please specify

* must provide value

Google Search

Facebook/Instagram

Twitter

International OCD Foundation

Location

* must provide value

Please specify

* must provide value

Expand

Do you see a MGH specialist on the main MGH campus?

* must provide value

Yes

No

Please provide the name of the specialist and their department

* must provide value

Expand

Have you ever participated in a research study in our clinic?

* must provide value

Yes

No

Please explain

* must provide value

Expand

Have you ever previously seen providers in the OCD clinic?

* must provide value

Yes

No

When?

* must provide value

Please provide the name of the provider(s) that treated you prior

* must provide value

Why did previous treatment end?

* must provide value

Expand

Do you have a Primary Care Physician (PCP) at MGH?

You can visit our FAQs on our website to learn more information

* must provide value

Yes

No

What is the name of your MGH PCP?

* must provide value

Location

* must provide value

Do you currently have a Therapist at:

* must provide value

What is the name of your current therapist?

* must provide value

Please select what kind of therapy or Cognitive Behavior Therapy (CBT)* you are currently enrolled in:

* 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.

* must provide value

Individual therapy or counseling, non-CBT

CBT, individual

CBT, group

Group therapy, non-CBT

Family or couples therapy

Self-help (i.e., AA, OA, ACOA, ALANON, etc.)

Inpatient

Residential

Other

Do you currently have a Psychiatrist at:

* must provide value

What is the name of your current Psychiatrist?

* must provide value

Please list all current psychiatric medications, including the prescribed dosage

* must provide value

Expand

Please specify other type of therapy:

* must provide value

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

* must provide value

OCD

BDD

Tic disorder

Trichotillomania

Skin Picking

Hoarding

Olfactory reference syndrome (ORS)

Has your OCD been diagnosed?

* must provide value

Yes

No

Has your BDD been diagnosed?

* must provide value

Yes

No

Has your Tic disorder been diagnosed?

* must provide value

Yes

No

Has your Trichotillomania been diagnosed?

* must provide value

Yes

No

Has your skin picking been diagnosed?

* must provide value

Yes

No

Has your hoarding been diagnosed?

* must provide value

Yes

No

Has your ORS been diagnosed?

* must provide value

Yes

No

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

* must provide value

What are your primary obsessions, fears, or concerns?

* must provide value

Expand

Do you experience Intrusive thoughts?

* must provide value

Yes

No

Are these intrusive thoughts sexual or harmful in nature?

* must provide value

Yes

No

Please give some examples of your intrusive thoughts

* must provide value

Expand

Do you have any compulsions or rituals?

* must provide value

Yes

No

Please describe your compulsions or rituals

* must provide value

Expand

What specific part(s) of your body do you have appearance concerns about?

* must provide value

Expand

What specifically about that part(s) are you concerned about?

* must provide value

Expand

Do you have shape and weight concerns?

* must provide value

Yes

No

Please explain your weight and shape concerns

* must provide value

Expand

Have you ever had an eating disorder?

* must provide value

Yes

No

How tall are you?

* must provide value

How much do you weigh?

* must provide value

Do you do anything to make yourself feel better about your appearance?

* must provide value

Yes

No

If yes, briefly explain.

* must provide value

Expand

Do you have motor tics?

* must provide value

Yes

No

What is the nature of the tic?

* must provide value

Expand

Do you have vocal tics?

* must provide value

Yes

No

What is the nature of the tic?

* must provide value

Expand

What areas do you pull your hair from?

* must provide value

Expand

Why do you pull your hair?

* must provide value

Expand

Do you have any spots of thinning or balding?

* must provide value

Yes

No

Where?

* must provide value

Expand

Where do you pick your skin from?

* must provide value

Expand

Why do you pick your skin?

* must provide value

Expand

Do you have noticeable skin damage?

* must provide value

Yes

No

Please briefly explain

* must provide value

Expand

What items do you collect and/or have difficulty discarding?

* must provide value

Expand

Are there areas in your home that you have a hard time walking through because they are too full?

* must provide value

Yes

No

Please explain

* must provide value

Expand

Please describe your primary symptoms

* must provide value

Expand

In the past 7 days, how much of your time is occupied by obsessive thoughts? How frequently do the obsessive thoughts occur?

* must provide value

None

1-3 hours

3-5 hours

5-8 hours

>8 hours

How much does your obsessive thoughts interfere with your social or work functioning?

(If you are not currently working, please think about how much the obsessions interfere with your daily activity)

* must provide value

None

Mild

Moderate

Severe

Have you been prescribed psychiatric medication in the past?

* must provide value

Yes

No

Please list the medications, their dosage and why you were taking them.

* must provide value

Expand

Who prescribed your medication?

* must provide value

Have you been in therapy in the past?

* must provide value

Yes

No

Please select what kind of therapy or Cognitive Behavior Therapy (CBT) were you enrolled in, in the past:

* must provide value

Individual therapy or counseling, non-CBT

CBT, individual

CBT, group

Group therapy, non-CBT

Family or couples therapy

Self-help (i.e., AA, OA, ACOA, ALANON, etc.)

Inpatient

Residential

Other

Please explain other

* must provide value

Please provide the therapists name.

* must provide value

Do you have any other psychiatric diagnosis?

* must provide value

Yes

No

Please list any other psychiatric diagnosis.

* must provide value

Do you ever have odd or unusual experiences, like hearing or seeing things other people don't, or feeling like people are trying to follow you or hurt you?

* must provide value

Yes

No

If yes, please describe:

* must provide value

Expand

Have you had any psychiatric hospitalizations?

* must provide value

Yes

No

How many times have you been hospitalized?

* must provide value

When was your more recent hospitalization?

* must provide value

Where was your most recent hospitalization?

* must provide value

Did you try to harm yourself?

* must provide value

Yes

No

If yes, please explain

* must provide value

Expand

Please describe the reasoning for your most recent hospitalization

* must provide value

Expand

Have you had any alcohol in the past 3 months?

* must provide value

Yes

No

If yes, how frequently?

(For example 2 drinks per day, or two drinks per week)

* must provide value

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

* must provide value

Yes

No

Check all that apply:

* must provide value

Cocaine

Heroin

Abused prescription drugs

Other

If 'Other' please specify

* must provide value

Do you currently use marijuana?

* must provide value

Yes

No

Which method do you use?

(Check all that apply):

* must provide value

Smoke

Edible

How frequently do you use marijuana?

* must provide value

Have you ever tried to harm yourself?

* must provide value

Yes

No

How many times?

* must provide value

When?

Did you have to be to be hospitalized as a result?

* must provide value

Yes

No

What did you do?

* must provide value

Expand

Are you currently experiencing any thoughts of suicide?

* must provide value

Yes

No

How often have you had these thoughts over the past couple of days?

* must provide value

Rarely, once in the past couple of days

Twice, or more in the last couple of days

Approximately every hour

Several times an hour

When you had these thoughts over the past couple of days, how intense have they been?

* must provide value

Very weak

Weak

Moderate

Strong

How likely do you think you are
to act on these feelings?

* must provide value

Not at all likely

Very unlikely

Unlikely

Possible

Likely

Very likely

Definite

Have you made preparations for a suicide attempt?

If the patient says YES- Get a clinician

* must provide value

Yes

No

Do you have a current provider who you can discuss these thoughts with? Have you attempted in the past?

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 instead call 911 or go to the nearest emergency room.

* must provide value

Expand

Would you be interested in receiving a call from one of our staff members to learn more about the different options that our clinic offers?

* must provide value

Yes No

What type of treatment are you looking to receive through our clinic?

* must provide value

CBT/Therapy

Medication

Consult only

Please explain

* must provide value

Expand

Would you be interested in joining a CBT group instead of individual therapy if it meant you could be seen sooner?

* must provide value

Yes

No

Would you be interested in joining a CBT group following your individual therapy to continue to get additional support?

* must provide value

Yes

No

Reviewers Initials

Status:

Intake communication

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Research communication

Expand

Risk assessment from Clinician

Expand

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