Psychiatry Intake Form
PLEASE TYPE IN ALL CAPITAL LETTERS
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Email *
 **(PLEASE SUBMIT YOUR RESPONSES IN ALL CAPITAL LETTERS)**
Gender *
Last Name *
First Name *
Date of birth *
MM
/
DD
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YYYY
Marital Status: *
Race *
Ethnicity
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 1 *
City / Town *
Zipcode *
Emergency contact name *
Emergency contact phone *
Emergency contact relationship
Primary Care Doctor *
Please select the service(s) you are seeking *
Required
If you are interested in therapy services, are you comfortable with both male and female providers?
If you are applying for Medication Assisted Treatment (MAT) for Alcohol Use or Opioid Use Disorder please use the below link:
https://goo.gl/forms/UsYJP92tQqafAWP33
If you are interested in learning more about Transcranial Magnetic Stimulation (TMS) or scheduling an evaluation, please complete form linked below:
Diagnoses / Reason for Visit *
Required
Please check any medication(s) that you are currently prescribed or have been prescribed in the past 12 months.              
**Non-disclosure of controlled medication, or the inclusion of controlled medication not consistent with the Massachusetts Prescription Monitoring Program (PMP) will result in your form being rejected.**
Are you currently being treated for by Mental Health or Substance abuse provider or program? *
If you answered yes to the previous question, please explain why you are seeking to transfer your services?
Have you been incarcerated (in prison) in the last 12 months? *
If you answered yes to the previous question, please provide the reason for your incarceration
What is your current living status? *
Primary Insurance *
Primary Insurance ID # *
Secondary Insurance
Secondary Insurance ID #
Are either of your insurance carriers a Medicare Advantage (also called Medicare Part C or Medicare Replacement plan)?  *
Are you available to schedule your first appointment on short notice?
Clear selection
Have you been seen at Advanced Psych Services before? *
Required
Party completing form: *
Referred by: *
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
Please list the name, street and city of your preferred pharmacy? (e.g. CVS on Front St Worcester) *
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. *
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. *
Required
For more information, please visit our website at www.psychma.com
Thank you for choosing Advanced Psych Services
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