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.
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Yes
No
What is your relationship with the patient? * must provide value
Parent Other
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
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Today M-D-Y
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Today M-D-Y
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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
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 She They Ze A pronoun not listed No pronoun preference
If you selected a "pronoun not listed," please write in your preferred pronoun.
Are you currently pregnant or trying to conceive?
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Yes No Not applicable
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.
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Is it okay to leave a voicemail on this line?
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Yes
No
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Use send secure Opt-out of send secure
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
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How did you hear about us? Check all that apply
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Online
Flyer
Print Ad
Doctor
MBTA (public transportation, the T)
Other
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If a doctor, please specify.
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MGH Non-MGH
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Google Search
Facebook/Instagram
Twitter
International OCD Foundation
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Have you ever participated in a research study in our program?
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Yes
No
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Do you have a Primary Care Physician (PCP) at MGH?
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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)* are you 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:
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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:
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Which disorder are you looking to receive treatment for? (Check all that apply):
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OCD
BDD
Tic disorder
Trichotillomania
Skin Picking
Hoarding
Olfactory reference syndrome (ORS)
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?
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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?
* must provide value
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
* must provide value
* must provide value
Do you do anything to make yourself feel better about your appearance?
* must provide value
Yes
No
* must provide value
* must provide value
Yes
No
What is the nature of the tic?
* must provide value
* must provide value
Yes
No
What is the nature of the tic?
* must provide value
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
* must provide value
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
* must provide value
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?
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Yes
No
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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.
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Who prescribed your medication?
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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
* must provide value
Please provide the therapists name.
* must provide value
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?
* must provide value
Yes
No
* must provide value
Have you had any psychiatric hospitalizations?
* must provide value
Yes
No
How many times have you been hospitalized?
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When was your more recent hospitalization?
* must provide value
Where was your most recent hospitalization?
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Did you try to harm yourself?
* must provide value
Yes
No
* must provide value
Please describe the reasoning for your most recent hospitalization
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Have you had any alcohol in the past 3 months?
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Yes
No
If yes, how frequently?
(For example 2 drinks per day, or two drinks per week)
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Have you used any type of street drugs or abused drugs in the past 3 months?
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Yes
No
* must provide value
Cocaine
Heroin
Abused prescription drugs
Other
If 'Other' please specify
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Do you currently use marijuana?
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Yes
No
Which method do you use?
(Check all that apply):
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Smoke
Edible
How frequently do you use marijuana?
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Have you ever tried to harm yourself?
* must provide value
Yes
No
* must provide value
Did you have to be to be hospitalized as a result?
* must provide value
Yes
No
* must provide value
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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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?
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Very weak
Weak
Moderate
Strong
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
* must provide value
Yes
No
Do you have a current provider who you can discuss these thoughts with? Have you attempted in the past?
Resources for the patient if they need support:
National Suicide Prevention Lifeline 1-800-273-8255
Samaritans Hotline (877) 870-4673
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Would you be interested in hearing more about the different treatment options that our program offers?
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Yes No
What type of treatment are you looking to receive through our clinic?
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CBT/Therapy
Medication
Consult only
* must provide value
Pending Wait-list Refer out Research
Was the patient emailed the cancellation policy during scheduling?
Yes No
Risk assessment from Clinician
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