Request an Appointment

Emergency Assistance

If this is an emergency, call:

Crisis Line: 988

Client Information

First Name

Last Name

Sex as listed on insurance policy

Gender

preferred pronouns (i.e. she/her)

DOB

Age

First Name (parent/guardian)

Last Name (parent/guardian)

Phone

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Yes

I agree with Privacy Policies and Terms of Service linked below

Yes

Privacy Policies

Are you a healthcare (or other) professional placing a referral on the behalf of someone who is seeking services?

Yes

How did you hear about us?

Online search

Insurance search

Friend/family member

Other

Name of referral source

Please provide any details

Your name

Your phone number

Your email address

Your relationship to the client being referred

Service Type

Which service(s) are you interested in receiving?

Individual Therapy

at this time we are only able to accept new referral for clients 12 and older

Couples Therapy

at this time we are accepting referrals for our waiting list only for partners with daytime availability (2PM or earlier) at least one consistent weekday Mon-Fri

Family Therapy

unfortunately we are not accepting new referrals for family therapy at this time

Group Therapy

Partner's Name

Partner's DOB

Partner's Phone Number

Partner's Email Address

Which service(s) is the client interested in receiving?

Individual Therapy

at this time we are only able to accept new referral for clients 12 and older

Couples Therapy

at this time we are accepting referrals for our waiting list only for partners with daytime availability (2PM or earlier) at least one consistent weekday Mon-Fri

Family Therapy

unfortunately we are not accepting new referrals for family therapy at this time

Group Therapy

Partner's Name

Partner's DOB

Partner's Phone Number

Partner's Email Address

Insurance Information

please note that current availability is limited to Aetna, BCBS, Carelon (WellSense, Fallon, GIC), Tufts Commercial plans, Harvard Pilgrim, and United Healthcare and is dependent upon availability and client preferences

limited availability for individuals with other insurances, additional details provided in follow up as requested

Primary Insurance Provider

Member ID

Secondary/Supplemental Insurance

Member ID

Availability for Appointments

Days

Monday

Tuesday

Wednesday

Thursday

Friday

please provide additional details for times available on Mondays (i.e. 8AM-10AM, anytime after 2PM, etc)

please provide additional details for times available on Tuesdays (i.e. 8AM-10AM, anytime after 2PM, etc)

please provide additional details for times available on Wednesdays (i.e. 8AM-10AM, anytime after 2PM, etc)

please provide additional details for times available on Thursdays (i.e. 8AM-10AM, anytime after 2PM, etc)

please provide additional details for times available on Fridays (i.e. 8AM-10AM, anytime after 7AM, etc)

Preferences

Preferred Appointment Location

in person

virtual (telehealth)

Would you be open to telehealth appointment options if that meant we could get you started sooner?

Yes

Please make at least one selection

I would only be interested in working with a clinician who identifies as a female

I would only be interested in working with a clinician who identifies as a male

I would prefer to work with a clinician who identifies as a female, but am open to other options

I would prefer to work with a clinician who identifies as a male, but am open to other options

Other

Please make at least one selection

The client is only interested in working with a clinician who identifies as a female

The client is only interested in working with a clinician who identifies as a male

The client would prefer to work with a clinician who identifies as a female, but is open to other options

The client would prefer to work with a clinician who identifies as a male, but is open to other options

Unsure of client's preference

Please explain

Would you be open to working with a graduate level intern if the option was available?

Yes

Would the client be open to working with a graduate level intern if the option was available?

Yes

Reason for Appointment

please provide a brief explanation of the issues you are looking to have addressed, as well as any additional details you would like us to know about what you are looking for

please provide a brief explanation of the issues the client is looking to have addressed, as well as any additional details that would be relevant for us to know about the services they are seeking

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