Appointment Request

Emergency Assistance

This form is not monitored for emergencies. If you are in crisis, please contact local emergency services or a crisis hotline.

911
1.800.981.HELP (4357)

Client Information

First name

Last name

Pronouns

Optional

Email address

Phone number

Used only if email contact is unsuccessful

This referral is for

Myself Someone else

Please obtain the client's consent before submitting

Referral's name and email

Please share your contact here and the client's contact above

Due to licensure and regulations, we can only see clients who are physically in Massachusetts. We currently offer virtual sessions only. Can you confirm that you will be in MA during virtual sessions? We cannot accept clients who are outside of MA

Yes No

Are you looking for a therapist who specializes in working with Asian or Asian American clients?

Yes No

Do you have any preferences regarding the gender of your therapist?

No preference Female Male

Do you prefer a therapist who understands any of the following languages? Currently available languages

No preference

Cantonese

Mandarin

Korean

Thai

Vietnamese

Nepali

Hindi

Insurance Information

You can check whether your plan is in-network or has out-of-network benefits here:
https://www.elephantroomcounseling.com/services/payment-options

Insurance Name

Each therapist has different contracts with the insurance companies. Superbill is available for out-of-network plans.

Insurance Policy Number

Date of birth

Used for insurance verification only

Copy of insurance card - Front and back You may be asked to email it if we are unable to verify your insurance with the information provided.

Add file

Please upload a file

Preferred day(s) Please share your general availability so we can explore scheduling options.

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

Preferred time(s)

Early morning

6 am - 8 am

Morning

8 am - 10 am

Late morning

10 am - 12 pm

Early afternoon

12 pm - 2 pm

Mid afternoon

2 pm - 4 pm

Late afternoon

3 pm - 5 pm

Evening

6 pm - 9 pm

Late evening

9 pm - 12 am

If you feel comfortable, please share a brief summary of what brings you here.

You do not need to share details you are not ready to discuss.

We do our best to match you with a therapist based on your preferences and availability. Thank you for taking the time to reach out.

Your information will be encrypted.

Elephant In The Room Counseling

By submitting this form, I acknowledge this is not a clinical intake form. A member of our team will follow up with details and next steps.

(617) 657-3381‬
www.elephantroomcounseling.com
859 Willard Street, Suite 400, Quincy, Massachusetts, 02169, United States