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.
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Yes
No
What is your relationship with the patient?
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Parent Other
If Other
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Please provide your full name:
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Please provide your email address:
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Please provide your phone number:
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Today M-D-Y
Date of Birth
For individuals who are under the age of 18 : https://mghocd.org/pediocdtic/
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What is your current gender identity?
Female Male Transgender Genderqueer or Nonbinary I prefer not to say Unsure Another identity
Transgender Male/Transgender Man/ Female-to-Male (FTM) Transgender Female/Transgender Woman/Male-to-Female (MTF) Choose not to disclose
What is your gender identity?
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
If you selected "another identity," please provide how you identify:
What sex were you assigned at birth on your original birth certificate?
Male Female Choose not to disclose
What are your pronouns? (e.g., how do you prefer others refer to you, such as 'she opened the door,' or 'he said hello')
He / him / his / himself She / her / hers / herself They / them / their /theirs / themself Ze / hir / hirs / hirself Another set of pronouns; please, specify: _______________ No pronouns; Just say my name please Prefer not to answer
If you selected a "another set of pronouns" please write in your preferred pronoun.
Are you currently pregnant or trying to conceive?
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Yes No Not applicable
Do you have a disability (i.e., a physical or mental impairment that substantially limits one or more major life activities)?
No Hearing Vision (even when wearing glasses) Cognitive Mobility Self-care or independent living Other disability, specify: _______________ Prefer not to answer
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
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Is it okay to leave a voicemail on this line?
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Yes
No
Use send secure Opt-out of send secure
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
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How did you hear about us? Check all
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If a HealthCare provider, please specify.
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Massachusetts General Hospital (MGH) Outside Massachusetts General Hospital (MGH) MassGeneral Brigham (MGB) provider
Please provide the name of the referring MGH doctor
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Do you see a MGH specialist on the main MGH campus?
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Yes
No
Please provide the name of the specialist and their department
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Have you ever participated in a research study in our clinic?
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Yes
No
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Have you ever previously seen providers in the OCD clinic?
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Yes
No
Please provide the name of the provider(s) that treated you prior
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Why did previous treatment end?
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Do you have a Primary Care Physician (PCP) at MGH?
You can visit our FAQs on our website
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Yes
No
What is the name of your MGH PCP?
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Do you currently have a Therapist at:
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MGH Outside MGH No current Therapist
What is the name of your current therapist?
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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
Do you currently have a Psychiatrist at:
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MGH Outside MGH No current psychiatrist
What is the name of your current Psychiatrist?
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Please list all current psychiatric medications, including the prescribed dosage
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Please specify other type of therapy:
* must provide value
Which disorder are you looking to receive treatment for? (Check all
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Has your OCD been diagnosed?
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Yes
No
Has your BDD been diagnosed?
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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?
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OCD BDD Tic disorder Trichotillomania Skin Picking Hoarding Olfactory reference syndrome (ORS)
What are your primary obsessions, fears, or concerns?
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Do you experience Intrusive thoughts?
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Yes
No
Are these intrusive thoughts sexual or harmful in nature?
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Yes
No
Please give some examples of your intrusive thoughts
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Do you have any compulsions or rituals?
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Yes
No
Please describe your compulsions or rituals
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What specific part(s) of your body do you have appearance concerns about?
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What specifically about that part(s) are you concerned about?
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Do you have shape and weight concerns?
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Yes
No
Please explain your weight and shape concerns
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Have you ever had an eating disorder?
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Yes
No
Do you do anything to make yourself feel better about your appearance?
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Yes
No
Yes
No
What is the nature of the tic?
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Yes
No
What is the nature of the tic?
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What areas do you pull your hair from?
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Why do you pull your hair?
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Do you have any spots of thinning or balding?
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Yes
No
Where do you pick your skin from?
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Why do you pick your skin?
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Do you have noticeable skin damage?
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Yes
No
What items do you collect and/or have difficulty discarding?
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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 describe your primary symptoms
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In the past 7 days, how much of your time is occupied by obsessive thoughts? How frequently do the obsessive thoughts occur?
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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)
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None
Mild
Moderate
Severe
Have you been prescribed psychiatric medication in the past
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Yes
No
Please list the medications, their dosage and why you were taking them.
* must provide value
Who prescribed your medication?
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Have you been in therapy in the past
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Yes
No
Please select what kind of therapy or Cognitive Behavior Therapy (CBT) were you enrolled in, in the past
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Please provide the therapists name.
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Do you have any other psychiatric diagnosis?
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Yes
No
Please list any other psychiatric diagnosis.
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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?
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Yes
No
Have you had any psychiatric hospitalizations?
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Yes
No
How many times have you been hospitalized?
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When was your more recent hospitalization?
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Where was your most recent hospitalization?
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Did you try to harm yourself?
* must provide value
Yes
No
Please describe the reasoning for your most recent hospitalization
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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
If 'Other' please specify
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Do you currently use marijuana?
* must provide value
Yes
No
Which method do you use?
(Check all
* must provide value
How frequently do you use marijuana?
* must provide value
Have you ever tried to harm yourself?
* must provide value
Yes
No
Did you have to be to be hospitalized as a result?
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Yes
No
Are you currently experiencing any thoughts of suicide?
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Yes
No
How often have you had these thoughts over the past couple of days?
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When you had these thoughts over the past couple of days, how intense have they been?
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How likely do you think you are to act on these feelings?
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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
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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.
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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?
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Yes No
What type of treatment are you looking to receive through our clinic?
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Would you be interested in joining a CBT group instead of individual therapy if it meant you could be seen sooner?
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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
Pending Wait-list Refer out Research
Risk assessment from Clinician