General Intake Form and Questionnaires

For your convenience, links to intake and questionnaire forms are provided below. Prior to returning any questionnaires, your child’s primary care physician must submit an intake form and an insurance referral, as some require a prior authorization.

PLEASE SEND US COMPLETED PACKETS WITHIN THREE MONTHS OF REFERRAL.

We will contact you for an appointment. Wait times can vary.

While you are waiting for an appointment, if your child is:

Physicians: Please complete the intake form and email it to us. You can provide your patient’s family with the questionnaires or direct them to this website to download a copy.

Parents: You may download the parent and teacher questionnaires that are appropriate for the age of the child being referred. Once completed, mail or email them to the DBP office. Your information will be evaluated by our physicians and, if appropriate, we will contact you to schedule an appointment.

 

For those younger than 3 years, please complete the MCHAT-R.

 

 

 

Appointments: 855-UMASS-MD

Children's Medical Center
University Campus
55 Lake Avenue North
Worcester, MA 01655

 

Children's Hospital Association 

 

Telephone: 774-442-3028

UMass Memorial Medical Center
University Campus - Benedict Building
55 Lake Avenue North
Worcester, MA 01655