About You
First Name
*
Last Name
*
Phone
*
Email
*
Is the Client a Minor?
*
Yes
No
Guardian Name
Guardian Email
Availability
State of Residence
*
Client's Availability for Sessions
Nearly Always Available/Will try to make any time work
Week Days 8AM to 3PM
Week Days 3PM to 6PM (limited availability)
Week Days 6PM to 8PM (limited availability)
Weekends
Other
How would you like to meet?
Telehealth (online)
In-person: Bourne
In-person: West Yarmouth
In-person: Boston
Reasons for seeking Therapy (Choose all that Apply)
*
ADHD
Anxiety
Autism
Conduct/Behaviour Issues
Depression
Eating Disorder
Grief
Identity (gender or sexual)
LGBTQ (you would like to be placed with a therapist who is part of or specialzes in the LGBTQ community)
OCD
Personal Relationships
Personal Wellbeing/Improvement
PTSD
Recent Discharge from a Hospital
Substance Use or Addiction
Specific Phobia (Please click here and elaborate by clicking other and giving more information in the text box)
Transition/Life Changes
Trauma
Other
Insurance
Payment Plan (if you see it on your card)
What Insurance Company do you Use? (These are Insurance Companies we Accept)
*
Aetna
Anthem
Blue Cross Blue Shield
Blue Benefit Administrators of MA
Fallon Health
Harvard Pilgrim
Optum
Tufts
United Healthcare
Self Pay
Other (Please contact our Client Service Coordinator
[email protected]
)
Please Specify Other Insurance here
Schedule Appointment
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