617-401-7700
tms@obhi.org
1506 Providence Highway, Suite 25 Norwood MA 02062
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Telemedicine
Contact Us
Intake
Intake Form
Patient Name:
Who is filling?
Self
Father
Mother
Husband
Wife
Date:
General
Date of Birth:
Phone Number:
Email:
Address:
Type of service: (Select from the boxes below) *
Psychiatry- Medication Management
Therapy- CBT, DBT, EMDR, etc. (Does NOT prescribe medications)
Transcranial Magnetic Stimulation (TMS)
Spravato (Esketamine)
How did you hear about us:
Insurance Company:
Member ID:
Insurance Card (Front)
Insurance Card (Back)
Patient Related
Please explain why you are seeking services:
List all current medications and dosages:
Have you had any recent or past in-patient mental health hospitalizations?
Yes
No
If yes, when was the last hospitalization and what was it for?
Have you had any recent or past suicide attempts:
Yes
No
If yes, was it within the last 6 months?
Yes
No
Do you currently have any thoughts of harming yourself or others?
Yes
No
IF YES, PLEASE CONTACT 911 IMMEDIATELY OR GO TO YOUR LOCAL EMERGENCY ROOM.
Is there any history of violence towards others?
Yes
No
If yes, was this verbal or physical?
Do you now or ever had any history of drug or alcohol abuse?
Yes
No
If yes, are you currently using?
Yes
No
*If patient is under 18* Any DCF or DMH involvement?
Yes
No
N/A
If yes, do the parent(s) have full custody?
Yes
No
N/A
SUBMIT
