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Clinical & Research Program for Autism Spectrum Disorder

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Should you encounter any difficulties while completing this form, please do not hesitate to contact us. We would be pleased to assist you throughout the process.

617-726-7899

Description:

This form is intended for adults and parents of minors to provide relevant health information to our care team for the purpose of triaging patients effectively. Age criteria for this clinic is 6-45 years.

Instructions:

Please complete this questionnaire to provide more information about your mental health concerns. This information will help us determine eligibility and fit for this clinic and relevant clinical trials. Please note that this information is being collected on a Health Insurance Portability and Accountability Act (HIPAA)-compliant platform. The questionnaire will be saved to your medical record.

After you complete the form, please expect to hear from our staff within 10 business days.

Please keep in mind our clinic does not offer the following services:

Individual or family counseling
Neuropsychological testing
Case management services
Consulting with school staff or IEP/504 recommendations
Personalized referrals to community organizations

Important note: Some questions on this form may appear or disappear based on your responses.

* indicates a required field.

Requestor Information

Who is completing this form?

Your first name

Your last name

Relationship to Patient

Patient Information

Kindly answer the following following questions as they relate specifically to the patient.

Patient first name

Patient last name

Patient date of birth

MM/DD/YYYY

In which state does the patient reside?

Patient phone

Patient email address

Sex assigned at birth

Gender identity

Please specify

Insurance Provider/Plan name (i.e. BCBS, Select HMO)

Has the patient ever received medical care at a Mass General Brigham hospital?

YesNo

Please enter patient's MGH medical record number

Name of patient's Primary Care Physician (PCP)

Does the patient have an intellectual disability (ID)?

YesNo

Can the patient verbally communicate?

YesNo

Who is the patient's legal guardian?

SelfParentCourt-appointed guardian

What is the patient's marital status?

SingleMarriedCivil union/life partner, Legally separatedDivorcedWidowedPatient is a minorDecline/Prefer not to say

Is the patient currently receiving disability benefits or services? (e.g, DDS, DMH, MRC, Therapeutic school placement, etc.)

YesNo

If yes, please list services received to the best of your knowledge, or write 'N/A' if not applicable.

Which of the following best describes the patient's current work situation?

Employed (full or part-time)Unemployed and not seeking work (e.g. retired, homemaker)Unemployed and actively looking for workOn medical leaveReceiving disability benefits (e.g. On Social Security Disability Insurance (SSDI))Student

Referral Information

Which condition(s) are you concerned about at this time?

Attention Deficit Hyperactivity DisorderAutism Spectrum Disorder

Who referred you to the MGH Bressler Program?

Psychiatrist/prescriberPsychotherapistPCPSelfOther

Please specify.

Please select the reason for this referral:

For a consultation onlyFor evaluation and managementSeeking second opinionSeeking transfer of care from an existing psychiatric provider (Psychiatrist or Nurse Practitioner)OtherPlease note, MGH Bressler Program does not provide any psychotherapy or educational/vocational support services including neuropsychological testing.

Please specify.

Symptoms

What are the major symptoms/problems the patient would like to address?

Examples may include sleep problems, memory loss, changes in appetite, difficulty doing things, developed tremors, or developmental delays.

Diagnosis

Has the patient ever been diagnosed with a mental health condition?

YesNo

Please check all the diagnoses the patient has received.

ADHDAutism Spectrum DisorderBipolar DisorderMajor Depressive DisorderAnxiety DisorderEmotional DysregulationOCDODDPanic DisorderPsychosis or SchizophreniaPTSDNoneOther

Current Psychiatric Medications

Is the patient currently taking psychiatric medications?

YesNo

If yes, please provide names and doses of current medication(s), or write 'N/A' if not applicable.

List the generic or brand name.

Is the patient currently followed by a prescribing Psychiatrist or Psychiatric Nurse Practitioner?

YesNo

If yes, please list the name of your current prescribing psychiatric provider, or write 'N/A' if not applicable.

If the patient is prescribed psychiatric medications by someone other than a Psychiatrist or Psychiatric Nurse Practitioner, please share below the name of the prescriber.

Safety Concerns

Does the patient have any past or present self-injurious or suicidal behavior?

YesNo

If yes, please provide details, or write 'N/A' if not applicable.

Does the patient have a history of serious aggression or violence?

YesNo

If yes, please describe, or write 'N/A' if not applicable.

Has the patient ever been hospitalized for a psychiatric reason (including inpatient and/or partial program)?

YesNo

If yes, please provide the reasons, time, duration, and location of hospitalization, or write 'N/A' if not applicable.

Where is the patient being cared for at the time this form is being completed?

Living at homeLiving at home with outpatient care (may include in-home services)Living at home and attending a partial hospital programCurrently admitted at an inpatient psychiatric hospitalCurrently living in a residential program or a group homeOther

Please specify.

Substance Use

Does the patient have recent or ongoing substance or alcohol use?

YesNo

If yes, please describe substances used and the most recent time of use, or write 'N/A' if not applicable.

Does the patient have an ongoing legal proceeding?

YesNo

If yes, please describe, or write 'N/A' if not applicable.

Medical History

Does the patient have any major medical problems?

YesNoExamples may include seizure disorder, hypertension, diabetes, genetic disorder, etc.

Please describe.

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