General Intake Form and Questionnaires
For your convenience, links to intake and questionnaire forms are provided below. NOTE: 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:
- Under 3 years: Please connect with Early Intervention in your area.
- Over 36 months: Request a school evaluation through your public school system.
Physicians: Please complete the intake form and mail 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 them to the DBP office. Your information will be evaluated by our physicians and, if appropriate, we will contact you to schedule an appointment.
- DPB Intake Form
- RITA-T Intake Form
- Cuestionario para padres – Niños menores de 5 años
- Early Intervention Questionnaire
- School Questionnaire for Preschool or School-age Children
For those younger than 3 years, please complete the MCHAT-R.
Exclusive Health Care Provider for the Worcester Red Sox.