Not Accepting New Clients at This Time

Emergency Assistance

If this is an emergency, call:

911 or go to your local emergency room

Please Fill In Information below for the Client Information/Screening Form

Current or new client?

Current Client

New Client

Type of Service requested We are offering Telehealth only at this time.

Telehealth

Both Face to Face and/or Telehealth

First name

Last name

Address

City

State

Zip Code

Date of Birth

Email address

mobile phone

work phone number

Employer

Spouse/Partner or Parent

Child or Sibling Name

Age

Child or Sibling Name

Age

Child or Sibling Name

Age

About Your Appointment

What is the best day and time for your appointment? (provide 2 options)

Medical Information

Medical Information/medications

Mental Health medications

Insurance Information

If you are not using insurance put NONE in required field

Insurance Company

Member ID #

Group #

Subscriber

Subscriber DOB

Subscriber Relationship

Provider services or Behavioral health phone number on back of insurance card

Explain the reason you are seeking services

I understand that I will be asked to provide a copy of my driver's license or state issued photo ID and a copy of my insurance card before counseling begins.

Please note: cases are reviewed and accepted on a case by case basis.

Your information will be encrypted.

James J. Foster & Associates, LTD

James Foster & Associates LTD offers individual counseling for adults experiencing depression, anxiety and trauma. The therapists in this practice are trauma certified as well as certified as distance counselors.

+1-603-668-7744
www.counselingnh.com
540 Chestnut St., Suite 102, Manchester, NH, 03101