Request outpatient behavioral health treatment for adolescents and young adults

Urgent/Emergency Assistance

Massachusetts mental health support & resources: https://www.masshelpline.com/ or dial or text 833-773-2445
Suicide concerns: https://988lifeline.org/ or dial or text 988
If it is an emergency dial 911 or go to nearest emergency department. Or you can contact one of the psychiatric emergency numbers below.
Cape Cod and Islands 1-800-981-4357
Plymouth/Wareham area 1-877-996-3154

please complete the following

Legal first name

This for the person in need of treatment

Last name

Date of birth

Please note that my practice is now limited to adolescents and young adults

First name of parent/guardian (if necessary)

Last name

Email address

Phone number

Referral source

Name of Specific Insurance Plan

Note that I am in-network for the following plans: Aetna, BCBS, Harvard-Pilgrim, Tufts Commercial (unfortunately not the Direct plan), and Wellsense. I can take out-of-network and self-pay

Why is counseling being requested?

Please describe current and /or past treatments and providers.

Are parents married?

Yes No

Please describe custody arrangement.

If custody is shared, provide name, phone number, and email of the co-parent (as consent to treatment will be required for both parents is most cases).

Are parents involved in a custudy dispute?

Yes No

Describe details of custody dispute.

Feel free to provide me with any document that you think will be helpful.

Add file

Please upload a file

Please note additional information. Provide any accommodation needs (eg physical, cognitive, language, gender identity & sexual orientation, ). Prior to the intake session, you will have the opportunity to provide me with your concerns and history via the online intake documents.

You will receive an automatic confirmation email after submitting this form. Be aware that sometimes the emails are sent to the spam folder, I recommend correcting that issue as you might not receive future emails from myself in a timely manner.

Your information will be encrypted.

Adam D. Friedman, LMHC

Licensed Mental Health Counselor

Adam D. Friedman, LMHC is a Licensed Mental Health Counselor with over 30 years of counseling related experiences. In private practice since 2007, he provides treatment exclusively to adolescents and young adults. He has a warm, nonjudgmental, and engaging style. Clients often report that they immediately feel comfortable and that he is laid back and easy to talk to. He cares deeply about making progress and is highly committed to ongoing learning about the latest developments in the field. Feel free to learn more about me and my practice at meetmonarch.com/therapist/adam-d-friedman-lmhc-licensed-mental-health-counselor-bourne-ma .

774-836-3738 (call or text)
meetmonarch.com/therapist/adam-d-friedman-lmhc-licensed-mental-health-counselor-bourne-ma
243 Main St, Bourne, MA, 02532