Patient Intake Form (Adolescent)

Boston Psychiatric Alliance

(617) 291-6443

Client Information

First name

Last name

Date of birth

Gender

Parent or Guardiean Information

Phone number

Email address

Address

Relationship to Adolescent

Can we contact you by phone, email, and voicemail?

Yes No

If no, what is your preferred method of communication?

Emergency Contact

Add another emergency contact

In case of an emergency, do we have permissions to contact this person?

Yes No

Medical History

Has the adolescent previously received therapy?

Yes No

If yes, what is the therapist's name?

Has the adolescent previously been prescribed psychiatric medication?

Yes No

If yes, what medications are the adolescent currently taking?

Do you have any pre-existing medical conditions?

Is the adolescent pregnant?

Yes No Not sure

If yes, how far along?

Is there anything else regarding your medical history that we should be aware of?

Family History

Provide the name of the child's parents and briefly describe their relationship.

Does the adolescent have any siblings?

Yes No

If yes, please provide the names of the child's siblings and briefly describe their relationship.

Is there anything else regarding family history that we should be aware of?

Personal History

Is the adolescent in school?

Yes No

If yes, what grade?

Answer the following as they apply to the Adolescent:

Any trouble sleeping?

Regularly Occasionally No

Any regular exercise?

Regularly Occasionally No

Have a healthy and balanced diet?

Regularly Occasionally No

Do chores or tasks around the house?

Regularly Occasionally No

How often on the internet?

Regularly Occasionally No

Video games?

Regularly Occasionally Never

Interacts with their friends?

Regularly Occasionally No

How often do you have time for fun and recreational activities?

Regularly Occasionally Never

Is there anything else regarding that we should be aware of?

Reasons for Visit

Describe the reasons for seeking therapy.

Describe any goals or outcomes hoped to achieve from therapy.

Describe any significant life changes or stressful events that the adolescent have recently experienced.

Is there anything else you'd like to tell us about?

Consent for Telehealth Treatment

Introduction

Telehealth involves the use of electronic communications to enable health care providers to provide patient care through the means of live two-way audio and/or video. The purpose of this form is to obtain your consent to participate in a Telehealth consultation for various medical conditions/illnesses. The information may be used for diagnosis, Treatment, therapy, follow-up and/or education, and may include any of the following: Patient medical records, Medical images, Live two-way audio and/or video and Output data from medical devices and sound and video files as well as secure messaging through our HIPAA compliant telehealth app.

Confidentiality

Electronic systems used will incorporate network and software security protocols to protect the confidentiality of patient identification and imaging data and will include measures to safeguard the data and ensure its integrity against intentional or unintentional corruption. Reasonable and appropriate efforts have been made to eliminate any confidentiality risks associated with the Telehealth consultation and the software used by our office is HIPAA compliant. This means it meets appropriate requirements for patient privacy laws to keep your data as safe as possible.

Possible Risks

As with any medical procedure, there are potential risks associated with the use of Telehealth. These risks include, but may not be limited to: In rare cases, information transmitted may not be sufficient (e.g. poor resolution of images) to allow for appropriate medical decision making by the provider. There are potential risks to this technology, including interruptions, unauthorized access and technical difficulties. The session may be discontinued and rescheduled by the provider if the video conference connection is not adequate for the situation. It is the patient or their parent/legal guardian's responsibility to ensure the patient has a reliable internet connection to use for appointments. We understand extreme weather may cause unforeseen issues.

Your Rights

Consent to telehealth is required to receive services at our practice at this time. You may withhold or withdraw consent to the Telehealth consultation at any time. You are not required to receive services from Boston Psychiatric Alliance and other appropriate services that do not require telehealth consent are available. If you do withhold or withdraw consent, this may require us to provide you with a referral to another provider outside our office who can better meet your needs.

Office Telehealth Policies

I understand that I cannot be operating a motor vehicle while engaging in telehealth at BPA If it is found I am operating a vehicle during the appointment the clinician will immediately close the appointment session. I may be charged a late cancel/missed appointment fee and asked to reschedule the appointment at a later time. I understand it is my obligation to be in a private location where I can speak openly about my health during my telehealth appointment. My clinician can not be held liable for information heard by others near me from my end of the call. I will only allow those that I feel comfortable hearing my private health information around me during my telehealth call. I agree to behave in a respectable manner that would resemble an appropriate in-person interaction in an office setting. I understand that any minor children must be accompanied by a parent or legal guardian during their appointment unless previously discussed with the clinician that they may attend a telehealth session alone.

I Consent to Telehealth. I understand possible risks, my rights, and agree to the office telehealth policies.

HIPPA Consent and Release Form

HIPAA Consent as Applicable to the Adolescent

Our Notice of Privacy Practices provides information about how we may use or disclose protected health information.

The notice contains a patient’s rights section describing your rights under the law. You ascertain that by your signature that you have reviewed our notice before signing this consent.

The terms of the notice may change, if so, you will be notified at your next visit to update your signature/date.

You have the right to restrict how your protected health information is used and disclosed for treatment, payment or healthcare operations. We are not required to agree with this restriction, but if we do, we shall honor this agreement. The HIPAA (Health Insurance Portability and Accountability Act of 1996) law allows for the use of the information for treatment, payment, or healthcare operations.

By signing this form, you consent to our use and disclosure of your protected healthcare information and potentially anonymous usage in a publication. You have the right to revoke this consent in writing, signed by you. However, such a revocation will not be retroactive.

By signing this form, I understand that:

Protected health information may be disclosed or used for treatment, payment, or healthcare operations.
The practice reserves the right to change the privacy policy as allowed by law.
The practice has the right to restrict the use of the information but the practice does not have to agree to those restrictions.
The patient has the right to revoke this consent in writing at any time and all full disclosures will then cease.
The practice may condition receipt of treatment upon execution of this consent.

May we phone, email, or send a text to you to confirm appointments?

Yes No

May we discuss your medical condition with any member of your family?

Yes No

If YES (above), please name the members allowed:

HIPAA Release as Applicable to the Adolescent

Please complete all sections of this HIPAA release form. If any sections are left blank, this form will be invalid and it will not be possible for your health information to be shared as requested.

Section I

I give my permission for Boston Psychiatric Alliance to share the information listed in Section II of this document with the person(s) or organization(s) I have specified in Section IV of this form.

Section II

I would like to give the above healthcare organization permission to:

Disclose the complete health record including, but not limited to, diagnoses, lab test results, treatment, and billing records for all conditions.

Section III - Reason for Disclosure

Please detail the reasons why information is being shared. If you are initiating the request for sharing information and do not wish to list the reasons for sharing, write ‘at my request’.

Section IV - Who Can Receive My Health Information

I give authorization for the health information detailed in section II of this document to beshared with the following individual(s) or organization(s). I understand that the person(s)/organization(s) listed above may not be covered by state/federal rules governing privacy and security of data and may be permitted to further share the information that is provided to them. Please include Name, Organization, and Address below:

Section V - Duration of Authorization

All past, present, and future periods

Section VI - Agreement

I understand that:

I am permitted to revoke this authorization to share my health data at anytime and can do so by submitting a request in writing to Boston Psychiatric Alliance.
In the event that my information has already been shared by the time my authorization is revoked, it may be too late to cancel permission to share my health data.
I understand that I do not need to give any further permission for the information detailed in Section II to be shared with the person(s) or organization(s) listed in section IV.
I understand that the failure to sign/submit this authorization or the cancellation of this authorization will not prevent me from receiving any treatment or benefits I am entitled to receive, provided this information is not required to determine if I am eligible to receive those treatments or benefits or to pay for the services I receive.

Contract for Prescription of Controlled Medication

By Filling out and signing this form, I agree to the following conditions for treatment or the treatment of my minor child or person whom I have guardianship over with the following controlled medications and dosages:Please list out all controlled substance medications your provider has asked you to include in this contract. Be sure to include doses and the directions of how you take them *

Please list out all controlled substance medications your provider has asked you to include in this contract. Be sure to include doses and the directions of how you take them

By checking this box and signing this document I agree to the following:

I agree I will obtain the above listed medications covered by this contract solely from my provider at Boston Psychiatric Alliance or their covering provider. I will not fill a prescription for these medications from any other provider including my primary care doctor.

By signing this document you agree to the following:

I have read and understand the information in this document regarding the controlled medications addressed in this contract.
If I am transferring my care from another provider or practice it is my responsibility to provide prior medical records if requested. If these records cannot be obtained in a reasonable amount of time, the medication(s) will not be continued.
My prior records must verify the history I have provided, and my current Provider must agree with the prior treating provider’s rationale for the medication in order for it to be continued
My prescription(s) for these medication(s) may not be refillable, pursuant to regulation. Furthermore, these prescriptions can be prescribed or refilled only with written prescriptions, pursuant to regulation.
I will only obtain prescription(s) for these controlled medication(s) from the above Provider or the covering provider they designate. I understand that other members of the Provider’s group are under no obligation to provide refills for these medications. I understand that this contract applies to any covering clinician for my regular provider and that this clinician has no obligation to prescribe me the above medications if they deem it to be inappropriate to do so.
I will request refills for prescription(s) 3 days before the medication(s) run out in order to allow time to refill. Early refills are not given with the exception of extreme circumstances. I agree to treat the above listed medications like cash. If they are lost, stolen, or destroyed they cannot be replaced. Because of this I will keep them in a safe private place or keep them locked up to prevent theft or damage. (please initial in the box provided to show you understand this rule) *Enter your initials here to show you understand this rule.
I will notify the police if any of the above medication(s) are stolen from me. I understand that this notification or the existence of a police report does not mean I will get an early refill of the above listed medication(s).
I will inform all my providers of all the medication(s) prescribed to me as well as over the counter products I am using. I will notify all my providers of any changes in my condition. If a provider suggests prescribing any of the above listed medications I will inform them of this contract.
If I seek emergency/urgent care I will immediately notify the above Provider of any and all medications ordered or prescribed by the emergency/urgent care provider within 1 day of leaving or discharging the facility. This can be done by calling the office and leaving a voicemail, even on weekends and holidays.
If there is any need to change the pharmacy I will notify my Provider in advance and understand that medication refills may be delayed due to this change.
I understand that the existence of this contract may be shared with my pharmacy. I also understand that the above Provider may inform my other providers regarding the terms of this contract and the conditions and medication(s) it covers.
I also understand that my Provider above may be required to check available state databases to verify my prescription history. Discrepancies or evidence of untruthfulness may result in discontinuation of the prescription and/or my treatment relationship with this Provider and Group.
I agree to possible random drug testing as requested by my Provider. I agree that failure to provide a sample in the time frame specified or discrepancies in the test results can result in termination of my care with this Provider and Group.
I agree to be truthful and respectful to my Provider and their office staff at all times.
I agree to avoid improper use of controlled substances. This includes use of street drugs or deliberate overdosing, selling or trading medication. I understand these actions are dangerous and illegal and will lead to discontinuation of the prescription and my treatment relationship with the Provider and Group. I also understand diversion of these medications is a significant public health problem.
I agree to avoid weaning or abruptly stopping medication without notifying my Provider.
I understand that mixing these medications with alcohol or recreational drugs is dangerous and I will avoid doing so.
(For those who can become pregnant) I understand that if I become pregnant while taking these medications, health risks to my child may exist. I agree to contact my Provider immediately if I become pregnant or I am considering trying to conceive.
I understand that these medications are only one aspect of my care. Non-compliance with other care plan recommendations is a violation of this agreement and may lead to discontinuation of the prescription and my treatment relationship with this Provider and Group.
I understand my medications can be changed or stopped at any point in my treatment in my Provider’s discretion.
I understand these medications can lead to substance abuse and addiction in all persons. I will be truthful about my personal or family history of substance abuse to assist my Provider in protecting my safety.
I will keep all appointments with my Provider. If I need to reschedule I will do so in advance so that I can make an appointment before I run out of medication or refills. Prescriptions for the above medications will not be refilled prior to the rescheduled appointment. It is my responsibility to make sure this does not happen.
I understand that this agreement is specific to me and my Provider or covering provider and may not be continued if another provider takes over my care.
(For parents and legal guardians) If a parent of a minor or legal guardian to a disabled adult is suspected of or found to be taking, sharing, or misusing a patient's controlled medication in any way the patient's clinician is mandated to report this to the appropriate state agency. Additionally this may be grounds for discontinuation of the patient's controlled medication and discharge from Boston Psychiatric Alliance.

Psychiatric Medication Informed Consent

Purpose of Medication Treatment

I understand that psychiatric medications may be prescribed to treat mental health conditions such as depression, anxiety disorders, bipolar disorder, ADHD, PTSD, psychotic disorders, and related conditions. I understand that medication is part of a comprehensive treatment plan that may also include psychotherapy, lifestyle changes, and other interventions.

Voluntary Participation

I understand that:

Medication treatment is voluntary
I may accept or refuse any medication offered
I may discontinue medication at any time after discussing with my provider
My decision will not negatively affect my access to care

General Benefits of Psychiatric Medications

I understand that psychiatric medications may:

Reduce symptoms such as depression, anxiety, mood instability, inattention, or psychosis
Improve daily functioning and quality of life
Help prevent relapse or worsening of psychiatric conditions

General Risks and Side Effects

I understand that all psychiatric medications carry potential risks, including but not limited to:

Nausea, headache, gastrointestinal upset
Sleep disturbances (insomnia or sedation)
Changes in appetite or weight
Fatigue or restlessness
Sexual side effects
Emotional blunting or activation
I understand that side effects vary between individuals and medications, and not all risks can be predicted.

Serious but Rare Risks

I understand that some medications carry rare but serious risks, including:

Worsening depression or suicidal thoughts (especially early in treatment for some individuals)
Serotonin syndrome
Severe allergic reactions
Metabolic changes (e.g., diabetes, high cholesterol)
Liver, kidney, or thyroid effects (depending on medication)
Movement disorders or neurological side effects (rare)
I understand I should report any severe or concerning symptoms immediately.

Medication Class–Specific Risks

I understand that different medication classes carry additional risks:

Antidepressants (SSRIs/SNRIs): sexual dysfunction, initial anxiety increase, withdrawal symptoms if stopped abruptly
Antipsychotics: weight gain, sedation, metabolic syndrome, movement disorders
Mood Stabilizers: blood level monitoring, kidney/thyroid/liver effects, pregnancy risks (some agents)
Stimulants: decreased appetite, insomnia, increased heart rate/blood pressure, misuse potential
Benzodiazepines: dependence, tolerance, sedation, withdrawal risk
My provider will review specific risks before starting any medication.

Alternatives to Medication

I understand that alternatives to medication may include:

Psychotherapy (CBT, DBT, supportive therapy, etc.)
Lifestyle modifications (sleep, exercise, nutrition)
No treatment
Other non-medication interventions

Monitoring and Follow-Up

I understand that:

Regular follow-up appointments are required
Dose adjustments may be necessary
Certain medications may require lab work or vital sign monitoring
I am responsible for attending scheduled follow-ups for safe medication management

Emergency Guidance

I understand that psychiatric medications are not emergency treatments. If I experience severe side effects, suicidal thoughts, or a medical emergency, I will:

Call 911 or go to the nearest emergency department
Contact crisis services if needed
Not rely solely on my outpatient provider for emergencies

Medication Use Expectations

I understand that:

Medications must be taken only as prescribed
I should not share medications with others
Some medications may require gradual tapering to discontinue safely
I should inform my provider of all other medications or substances I use

By signing below, I acknowledge that:

I have had the opportunity to ask questions
My questions have been answered to my satisfaction
I understand the risks, benefits, and alternatives to psychiatric medications
I voluntarily consent to treatment with psychiatric medications under the care of my provider

Parent or Guardain Name

Signature

By typing your name above, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Date

Your information will be encrypted.