Intake Request FormPlease complete the form below to request services and we’ll be in touch within the week. Current Estimated Waitlist- 6-8 weeks Legal name of person seeking services: * First Name Last Name Preferred Name (If different): Preferred Pronouns: Date of birth: * MM DD YYYY Name and relationship of person completing this form (if not self): Email * Phone * (###) ### #### Address * Our providers are only licensed in MA and NH. We are unable to see clients who hold residence outside of those states. Address 1 Address 2 City State/Province Zip/Postal Code Country Do you have a preference for telehealth or in person sessions? * Telehealth In Person- Amherst In Person- Portsmouth Any What is your availability and it is flexible? * Please be as specific as possible so we can ensure availability at the time of your intake process. Frequency * Every week Every 2 weeks No preference Do you plan to use insurance? (If not, please select the "self-pay" option) * We are in network with Anthem BCBS, Aetna, Optum/United ,and Tufts Anthem BCBS Aetna Optum or United Tufts Self-pay Any questions or comments about insurance or payment? Please provide a general overview of why you are seeking out counseling services: * What is important to you in a counselor? * Have you had any psychiatric hospitalizations in the last year? Please describe. * Anything else you'd like to add? Thank you for submitting your request. Please allow 1-3 business days for us to review and we’ll be in touch via email!
