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Address: _________________________________________________

__________________________________________________________

E-Mail: __________________________________________________

Home Phone: (_____) __________________

Work Phone: (_____) __________________

Cell Phone: (_____) __________________

Today's Date: ____ / ____ / ____

• What clinician, if any, are you hoping to see?

__________________________________________________________

• Name of person whom you are seeking services for?
  (First Name, Middle Initial, Last Name)

___________________________   __________    ______________________________________

• What is your relationship to this person?

__________________________________________________________

• Date of Birth of potential client: ____ / ____ / ____

• Potential client's gender: ___ Male  ___ Female

• Has this individual or any other immediate family member ever been seen at our
  practice?
       (  ) Yes (  ) No  If yes, who? (Previous patient's name and clinician seen)

  _______________________________________________________________________________

• Marital Status (parent's marital status if completing intake for child)?

      ____ Single  _____ Married ____ Separated ____ Divorced ____ Re-Married

• Spouse/Parent's Name: _________________________________________________________

• If marital status is other than married, please list other parent's:

  Name: ___________________________________ Phone #: (______)________-______________

  Address:_________________________________________________________________________

 

• If you are a parent seeking treatment or evaluation for a child and are divorced
  or separated from the child's other parent, please answer the following questions:

* Do you have sole legal custody?  (  )Yes  (  ) No
  (Legal custody is not the same as Physical Custody. Sole legal custody means the
  parent legally has complete control to make decisions for the child.)

* Do you believe the other parent will consent to treatment? (  )Yes (  )No
  (consent of both parents is required)

* Is there currently, or do you anticipate a legal battle over custody, visitation,
  or anything related to the child? (  )Yes (  )No

• Who is the potential client's primary care physician?

  _________________________________  Telephone Number: (____) ________-_____________

• Where are they located? __________________________________________________________

• Who, if anybody, referred you to our practice? _____________________________________

• Do we have your permission to thank the person who referred you? (  )Yes (  )No

• Do you plan to use your health insurance to pay for our services? (  )Yes (  ) No

• If so, what type of health insurance do you have?_______________________________________

• Subscriber's name? __________________________________________________________

• Subscriber's Date of Birth: _______ / _______ / ______________

• Insurance Identification number? ________________________________  Suffix #: __________

• Subscriber's Social Security Number (required for United Health Plans) ________________________________

• Insurance telephone number for mental health benefits? (_____) ____________________

• When does your health plan renew? ____/____/________   Unsure: _____

• If Union plan or self-funded plan, phone number for contact person (____) _______________

• Do you have a secondary insurance?  (   ) Yes  (   ) No
  If yes, please complete:

  Subscriber's name: _____________________________________________________________________

  Subscriber's DOB:  _______/_______/___________  Social Security #: ______-_____-________

  Secondary Insurance Identification number: _____________________________________________

  Suffix #: _______________________

  Secondary Insurance telephone number: (______) _________________________________________

• When does your health plan renew? ____/____/________    Unsure: ______

• Has the potential patient used any mental health insurance benefits this
  calendar year? (  ) Yes  (  ) No

• If so, how many visits with a mental health clinician do you think you have
  used this year?  ______________________________

• Has the potential patient ever been hospitalized for psychiatric reasons?( )Yes( )No

• If yes, when was the last hospitalization? _____________________________

• Please briefly describe the nature of the problem you are seeking services for.

  ______________________________________________________________________________________

  ______________________________________________________________________________________

  ______________________________________________________________________________________

  ______________________________________________________________________________________




• List all medical symptoms or problems the patient has:

 

• List the names and professions of any other professionals you have consulted about
  these problems:

• What type of services are you seeking? Check all that apply.

  ( ) Unsure. Would like evaluation and recommendations for services.
  ( ) Medication
  ( ) Individual Psychotherapy
  ( ) Family Therapy
  ( ) Group Therapy, Which group? _________________________________ 
  ( ) Forensic Services
  ( ) Neuropsychological Evaluation
  ( ) Psychological Evaluation
  ( ) Mediation
  ( ) Consultation
  ( ) Developmental Evaluation
  ( ) Educational Therapy/Tutoring
  ( ) Other, please specify: __________________________________________________________

• If seeking medication, is patient in psychotherapy?  (  )Yes   (  )No
               Patients MUST be in ACTIVE therapy to see a psychiatrist at
               Child & Family Psychological Services.
• If Yes, how often seen on average?
                __weekly __every other week __monthly __less than monthly

• Therapist Name: __________________________ Therapist Phone #:(_____)____________________

• If potential patient is interested in seeing Dr. Lum or Dr. Paula Martin, can you come
  between 10:00AM - 2:00PM on a monthly basis?  (  ) Yes  (  ) No

• Do we have permission to leave a general message on your answering machine at
  home?                 At Work?          On Cell?
  ( ) Yes               ( ) Yes            (  ) Yes
  ( ) No                ( ) No             (  ) No

• When would you be able for services on a regular basis? Obtaining services after
  3 P.M. on weekdays are extremely difficult given the high demand. Please be
  sure to check all that apply:

  ( ) Anytime

  Please note: at this time most clinicians only have openings between 10:00AM - 1:00PM.

Please allow 7 - 14 business days to complete intake process.

Please print out this form and fax it us at 781-551-3396,
or mail it to:
Child & Family Psychological Services
89 Access Road, Unit 24
Norwood, MA 02062