Steps from the Babcock Street T Stop Contact Us Message Us First Last PhoneEmail(Required) CommentsConsent(Required)I agree to the terms and conditions set by Back Bay Mental Health. By providing my phone number, I consent to receive text messages from Back Bay. I agree to the privacy policy.NameThis field is for validation purposes and should be left unchanged. Contact Details Phone 617-765-0625 Email info@backbaymentalhealth.com Address 975 Commonwealth Ave. Boston, MA 02215 New Patient Inquiry Form About YouYour Name(Required) First Last Date of Birth MM slash DD slash YYYY PhoneYour Email Address(Required) Your Address Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Do you have insurance? Yes No Primary InsurancePrimary Insurance IDDo you have secondary insurance? Yes No Secondary InsuranceSecondary Insurance IDWhat medications are you currently prescribed?Do you currently have any of the following providers?A Primary Care Doctor? Yes No A Psychiatrist? Yes No A Therapist? Yes No Primary Care Doctor (Full Name)Doctor Phone NumberCurrent Psychiatrist (Full Name)Psychiatrist Phone NumberIf Yes and seeking therapy services with Windward Mental Health, why are you leaving your current Psychiatrist?Current Therapist (Full Name)Therapist Phone NumberIf Yes and seeking therapy services with Windward Mental Health, why are you leaving your current Therapist?How did you hear about us? Internet Search Social Media Psychology Today Word of Mouth Hospital or Medical Provider Other Consent(Required) I agree to the privacy policy.I agree to the terms and conditions set by Back Bay Mental Health. By providing my phone number, I consent to receive text messages from Back Bay.PhoneThis field is for validation purposes and should be left unchanged. Third-Party Referral Form Thank you for referring your patient to Back Bay Mental Health. Our hours are Monday through Friday 9:00 am - 4:00 pm. Our program treats adults with general behavioral health concerns. Program content includes psychiatric assessment, group therapies and individual therapy. If you have any questions about this form, contact us at 617-765-0625.Date of Referral MM slash DD slash YYYY Name of Patient(Required) First Last Patient Address Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Best Contact NumberDate of Birth MM slash DD slash YYYY Insurance InformationInsurance CompanyInsurance IDGroup IDSubscriber NameGroup NumberSubscriber NameDate of Birth MM slash DD slash YYYY Phone Number to Verify BenefitsReffering Provider NameCredentialsAgencyPhoneEmail(Required) Length of Treatment RelationshipDate of most recent visit MM slash DD slash YYYY Clinical InformationPatient's current symptomsProvide a brief description of the patient's current symptoms, functional impairment and reason why needs are best met at IOP/IOS level of care: Safety ConcernsProvide a description of recent safety concerns including non-suicidal self-injurious behaviors, suicide behaviors or attempts, risk taking behaviors, inability to care for self and aggression or threats to others: Clinical GoalsPrimary GoalSecondary GoalCurrent Behavioral Health DiagnosesCurrent Behavioral Health Diagnosis 1Current Behavioral Health Diagnosis 2Current Behavioral Health Diagnosis 3Has the patient agreed to participate in Windward Mental Health's IOS if accepted? Yes No Is substance use an active concern? Yes No Is an eating disorder an active concern? Yes No Are treatment alternatives to IOS being considered? Yes No What are the alternatives that are being considered?Previous Mental Health Treatment Programs (include hospitalizations, PHP/IOP/IOS, outpatient and substance use treatments):Substance Use (current and history of problematic use)AlcoholTobaccoDrugsCaffeineCurrent Medication (name, dose and frequency):Medication allergies and adverse reactions:Is the patient compliant with medications? Yes No If not, what are identified barriers?What medication adjustments or changes are deemed necessary?Past Medical HistoryAny other pertinent social or trauma informationCurrent Outpatient TreatmentPsychiatristDieticianTherapistOtherPrimary CareAnticipated prescriber at discharge:*If the patient does not have a current outpatient prescriber, please list all referrals made for this patient, including statusComments/Other Relevant InformationConsent(Required) I agree to the privacy policy.I agree to the terms and conditions set by Back Bay Mental Health. By providing my phone number, I consent to receive text messages from Back Bay.EmailThis field is for validation purposes and should be left unchanged.
