New Patient Intake Form

Required Login

Please Login for Submit Form.

Success

Thank you! Form submitted successfully.

* Please Fill In All Required Field

Please Select Required Service

Medication Management

Psychotherapy/counselling/Duo Diagnosis

Please check at lease one service

First Name *

This field is required

Last Name *

This field is required

Date of Birth *

This field is required

Address *

This field is required

City *

This field is required

Zip *

This field is required

Phone Number *

This field is required

Email *

This field is required

Primary Insurance *

This field is required

Primary Insurance ID *

This field is required

Secondary Insurance (If Any) *

This field is required

Secondary Insurance ID

Check back of insurance card

Name of Company (If alternate mental health services provider stated on card)

This field is required

Copay

Check back of insurance card

Primary Care Physician

Check back of insurance card

Referred By

Check back of insurance card

Why are you seeking help? *

Check back of insurance card

Past inpatient hospitalizations in the last 6 months-1 yr (Diagnosis &treatments).

Check back of insurance card

Past outpatient services and Providers 6 months-1yr (Diagnosis, Treatment)

Check back of insurance card

Current Psychotropic Medications

Check back of insurance card

Substance Use/Abuse issue

Check back of insurance card

Current Controlled Substance use

Check back of insurance card

Hiring LMHC and LCSW CONTACT, [email protected] for more DETAILS

Success

Massachusetts law about mental health issues

SAMHSA

Hiring LMHC and LCSW contact, [email protected] for more details