Adult Intake Form

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

Per our clinic policy, if the intake form is being completed on behalf of someone else, our Intake Coordinator will need to speak directly to the individual seeking treatment.

Today's Date

Patient's Full 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 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?

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 an MRN we will not be able to process your intake form.

Current Address

Telephone Number

Is it okay to leave a voicemail on this line?

E-mail Address

E-mail Security Preference:

Information on E-mail Security

What is the name of your Insurance?

Please note, if your behavioral health benefits are covered through a different insurance and/or carve-out kindly include that information here as well

How did you hear about us?
Check all that apply

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

What is the name of your MGH PCP?

Do you currently have a Therapist at:

What is the name of your current therapist?

Do you currently have a Psychiatrist at:

What is the name of your current Psychiatrist?

Please list all current psychiatric medications, including the prescribed dosage

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, please specify your main concern for which you are seeking treatment for?

What are your primary obsessions, fears, or concerns?

Do you experience Intrusive thoughts?

Are these intrusive thoughts sexual or harmful in nature?

Please give some examples of your intrusive thoughts

Do you have any compulsions or rituals?

Please describe your compulsions or rituals

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

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

Do you have shape and weight concerns?

Please explain your weight and shape concerns

Have you ever had an eating disorder?

How tall are you?

How much do you weigh?

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

If yes, briefly explain.

Do you have motor tics?

What is the nature of the tic?

Do you have vocal tics?

What is the nature of the tic?

What areas do you pull your hair from?

Why do you pull your hair?

Do you have any spots of thinning or balding?

Where?

Where do you pick your skin from?

Why do you pick your skin?

Do you have noticeable skin damage?

Please briefly explain

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

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

Please explain

Please describe your primary symptoms

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

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)

Have you been prescribed psychiatric medication in the past?

Have you been in therapy in the past?

Please explain other

Do you have any other psychiatric diagnosis?

Please list any other psychiatric diagnosis.

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?

If yes, please describe:

Have you had any psychiatric hospitalizations?

When was your more recent hospitalization?

Where was your most recent hospitalization?

If yes, please explain

Have you had any alcohol in the past 3 months?

If yes, how frequently?

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

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

 Check all that apply:

If 'Other' please specify

Do you currently use marijuana?

Which method do you use?

 (Check all that apply):

How frequently do you use marijuana?

Have you ever tried to harm yourself?

How many times?

When?

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

What did you do?

Would you be interested in hearing more about the different treatment options that our program offers?

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

 (Check all that apply):