New patient scheduling form

PLEASE BE AWARE THAT TELEHEALTH SERVICES CAN ONLY BE PROVIDED IF YOU ARE RESIDING IN MASSACHUSETTS

Thank you for your interest in receiving services from Trust Therapeutics. We have a few questions we would like to ask in order to get you scheduled with the most appropriate clinician on staff. Some of the questions may seem intrusive, but the purpose is to match you up with the clinician that can be most helpful to you. If you feel uncomfortable with any questions, please feel free to decline answering.

Telehealth is a form of counseling provided online. It is offered by a licensed or certified therapist via a secure video or phone connection. Although Telehealth is a very convenient way of accessing counseling services, it is sometimes not the most suitable mode of therapy depending on the severity/ complexity of a client's concerns. If our clinical team deems that we cannot provide you with the most appropriate service, we will refer you to another agency.

Client Name

Date of Birth

Age

** Please note you must be 18 or older and have access to your insurance information in order to apply for services. If you are under 18, please also list your guardian's name, phone number, and email address. Guardians must consent to the treatment of a minor.

Guardian's Name

Email Address / Guardian's Email Address

Street Address

(for the provision of Telehealth services)

City

(for the provision of Telehealth services)

Zip Code

(for the provision of Telehealth services)

Phone number / Guardian's Phone Number

Is it okay for us to send appointment reminders to your email?

YES, send me email appointment reminders NO, do not send email appointment reminders

Phone type

Home Cell Work

Is it okay for us to call and/or leave messages/text at this phone number?

YES - Voice and Text Messages OK YES - Voice Message ONLY YES - Text ONLY NO - NO MESSAGES

Insurance Name

Insurance policy number

This is the number on the front of your insurance card

Please submit photo of insurance card - FRONT

Add file

Please upload a file

Please submit photo of insurnce card - BACK

Add file

Please upload a file

Preferred days and times for counseling

Due to high volume, appointments book quickly and we cannot guarantee availability. Please respond within 24 hours of email receipt.

Briefly, what is the reason you are seeking counseling at this time?

Are you seeking counseling for substance abuse issue?

YES NO

Are you currently involved in a domestic violence relationship or a relationship where you feel the other person is controlling or threatening you or your family members? ** For your safety, we do not encourage telehealth therapy where your partner is living with you.

YES NO

Are you currently or have you in the past ever experienced psychosis or hallucinations, meaning you hear or see things that others cannot? .

YES NO

Are you actively having feelings or thoughts of suicide?

YES NO

Have you in the past 6 months had feelings, thoughts or made a plan or attempt to harm yourself?

YES NO

Are you involved with DCF or has there been an active DCF case open within the past year?

YES NO

** If you answered yes to any of the questions, a clinician will reach out to conduct a further screening to ensure Trust is the best fit for you.

Preferred days and times for counseling:

Clinician Race or Gender Preference

Please select preferred language

English Spanish

We will try to find you your cultural preference however, if one is not available, are you willing to be flexible?

YES NO

If your culturally preferred clinician is not available, would you be interested in working with a black female life coach at an out of pocket expense? If yes, someone will be in contact with you with additional information.

Yes No

Other issues, concerns or helpful information for us to know to have the most successful relationship?

How did you hear about Trust Therapeutics LLC

Facebook Instagram LinkedIn Other N/A

Please indicate "other"

Additional referral sources Please indicate the name of the facility that referred you to Trust Therapeutics LLC

Community Agency/Clinic Hospital Emergency Room

Hospital name

N/A

Please provide the full name of the referral source

Please Include phone number and email address if available. Thank you

For urgent attention dial 911 or text 988 or call 1-800-273-TALK to speak with the Suicide and Crisis Hotline

Thank you for your time. I will review which clinician would be a good fit for you with a supervisor and one of our staff will be in contact soon.

Your information will be encrypted.

New patient scheduling form

PLEASE BE AWARE THAT TELEHEALTH SERVICES CAN ONLY BE PROVIDED IF YOU ARE RESIDING IN MASSACHUSETTS

PLEASE BE AWARE THAT TELEHEALTH SERVICES CAN ONLY BE PROVIDED IF YOU ARE RESIDING IN MASSACHUSETTS

Lisa L. Robinson, LMHC, LPC

CEO and Founder, Trust Therapeutics