Child Cognitive Behavior Therapy Intake Form

Thank you for your interest in the Mass General Child Cognitive Behavior Therapy Program. Our program delivers short-term problem-focused skills based therapy to patients ages 3-24 years, with a variety of issues including anxiety, depression, ADHD, and other difficulties. Our intake process helps determine whether our program is best suited to meet your child's needs, and will allow us to understand more about the children and families who are seeking care in our program. To begin the intake process, please complete the information below. We estimate that it will take about 5-10 minutes to complete.

Due to the high volume of patients we currently have a waitlist. You may need to wait up to several months for an initial evaluation.

PLEASE NOTE THAT THE CHILD CBT PROGRAM IS NOT AN URGENT CARE FACILITY
If you are seeking care for your child that is more urgent, and cannot wait a week to hear back from us, we are most likely not the appropriate referral for your child. If your child needs urgent psychiatric care, we would advise you to contact your nearest emergency room, or to talk to your child's pediatrician about referral to a clinician who might be able to evaluate them sooner.

Required fields are marked with an*

Date

Patient's first name*   

Patient's last name*   

Date of birth*   

Does the child/individual have a Mass General medical record number? If yes, please include:*   

Patient's primary insurance company*   

What do you consider his/her race to be?

Is he/she currently in school?*   

Classroom environment?

What is your relationship to the patient?*   

What are the names of the legal guardians of the patient, if the patient is under 18?

First parent's name:*   

Second parent's name:

Other:

Marital status of parents:*   

Current mailing address*   

Phone number at which you would like to be reached:*   

Is it okay to leave a message on this voice mail identifying our program?*   

What are your main concerns for you/your child for which you are seeking CBT?

Does he/she have any cognitive delays or intellectual disability?*   

Does he/she have a history of aggression or violence?*   

Has he/she ever been hospitalized for psychiatric reasons?*   

Other Treatment/Medication

Is he/she/you currently taking any psychiatric medications?*   

If yes, what medication?

Who is prescribing the medication?

Is he/she/you currently receiving psychotherapy?*   

If yes, with whom?

NOTE: Due to our present waitlist, we are temporarily restricting our services to patients with a Mass General affiliation. We wanted to ask you some information about your child's Mass General affiliation.

Does your child have any of the following current relationships with Mass General?*   

If yes, please add the doctor's name here.

How did you find out about the Child CBT Program?*   

Name of doctor or provider who referred you to our program