Intake Request Form

Please complete the form below to request services and we’ll be in touch within the week.

IMPORTANT NOTICE: This form is not intended for urgent matters and will not be read immediately.

For urgent assistance:

Legal name of person seeking services:

First Name

Last Name

Preferred Name (If different):

Preferred Pronouns:

Date of birth:

YYYY

Name and relationship of person completing this form (if not self):

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

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?