Psychotherapy Intake Form

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PLEASE TYPE IN ALL CAPITAL LETTERS

Email *

**(PLEASE SUBMIT YOUR RESPONSES IN ALL CAPITAL LETTERS)**

Gender *

Female

Male

Other

Last Name *

First Name *

Date of birth *

YYYY

Marital Status: *

Single

Married

Divorced

Legally Separated

Widowed

Race *

American Indian or Alaska Native

Asian

Black or African American

Native Hawaiian or Other Pacific Islander

White

Hispanic

Other

Ethnicity

Hispanic or Latino

Not Hispanic or Latino

Decline to Answer

Clear selection

Primary Language (if not English)

Primary Phone Number (No dash needed) *

(PLEASE SPECIFY CELL, HOME OR WORK)

Secondary Phone Number

(PLEASE SPECIFY CELL, HOME OR WORK)

Address *

City / Town *

Zipcode *

Emergency contact name *

Emergency contact phone *

Emergency contact relationship

Diagnoses / Reason for Visit *

ADD / ADHD *If you are seeking ADD/ADHD treatment please bring supporting documentation of that diagnosis to your first appointment*

Anxiety

Bipolar Disorder

Depression

Insomnia

Intellectual Disability

Obsessive Compulsive Disorder (OCD)

Personality Disorder

Post Traumatic Stress Disorder (PTSD)

Schizophrenia

Sleep Disorder

Substance Use (General)

Substance Use (Opioid Addiction)

Not Sure / Never Been Treated

Other:

Required

Primary Insurance *

Aetna

Blue Cross Blue Shield

Cigna Health / Evernorth

Commonwealth Care Alliance (CCA)

Fallon Community Health Plan

Wellpoint (GIC)

Harvard Pilgrim Health Care

Health New England (HNE)

Health Plans Inc

Mass General Brigham

Carelon Health Strategies (formerly MBHP)

Medicare

Tricare / Humana Military

Tufts Health Public Plans (Direct, Together, and Unify)

Tufts Health Plan (All Other Plans)

United Healthcare

Wellsense

**Mass Advantage (APS IS OUT OF NETWORK)

**Wellcare (APS IS OUT OF NETWORK)

Self Pay

Other:

Primary Insurance ID # *

Secondary Insurance

Secondary Insurance ID #

Have you been seen at Advanced Psych Services before? *

Yes

Required

Party completing form: *

Self

Relative

Caseworker

Hospital

Other:

Referred by: *

Current Patient

Hospital

Insurance Company

Other Doctor

Primary Care Physician (PCP)

Self Referral

Therapist

Other:

Required

Is there a specific provider you are requesting to see?

Additional Comments

Please indicate any additional information that would be helpful in scheduling an appointment

By checking this box, I hereby consent and authorize the rendering of medical care, including examination, diagnostic procedures and medical treatment by the Advanced Psych Services and its providers, staff and any designees, as may be necessary and deemed beneficial to the patient's care. I acknowledge that no guarantees have been made as to the effect of such examination or treatment on my condition. I understand that I have the right to make decisions concerning my health care, including the right to refuse medical and surgical procedures. *

Yes

Required

By checking this box, I hereby consent to receiving treatment via telehealth if necessary (including audio-only phone calls) as well as in-person visits. *

Yes

Required

For more information, please visit our website at www.psychma.com

Thank you for choosing Advanced Psych Services

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