Client's Legal Name
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First Name
Last Name
State You Reside In
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Best Contact Phone
*
(###)
###
####
Best Contact Email
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Client's Date of Birth
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MM
DD
YYYY
Type of Service
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Individual Talk Therapy
EMDR Therapy & Extended-EMDR Therapy
Child/Adolescent Therapy
Couples & Marriage Therapy
Family Therapy
Medication Management
Military & First Responder Liaison
Other Client Contact Information
For couples or family therapy services, provide the legal names, birth dates, phone numbers, and email addresses of any other participants.
For child/adolescent individual therapy services, list both parents’ legal names, phone numbers and email addresses regardless of current custody arrangements.
I prefer to be seen...
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In Person or Virtually
In Person Only
Virtually Only
Telehealth Acknowledegment
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By checking this box, you understand that to be seen virtually you must be physically located in the state your therapist is licensed in for the duration of the session.
Payment Source
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Aetna
Cigna/Evernorth
Optum/Harvard Pilgrim/United
Tricare
Tufts
Self Pay
*Military & First Responder Liaison is a free service*
What is bringing you in for services at this time? How long has this been going on? Has anything happened recently that made you decide to come in for services now?
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Are you currently taking any medications for physical or mental health issues? If yes, please specify which medications, dosage, and current prescriber.
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Have you ever been hospitalized for psychiatric reasons? If yes, please specify for what and how long ago.
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Are there any substance use issues currently or in the past? If yes, please specify use history.
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Do you have any current legal issues (criminal charges, probation/parole, family court issues, child custody issues, etc.)? If yes, please describe.
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I am active duty military/a veteran or a first responder.
(optional)
What is your typical availability for appointments?
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Therapist Preference
No Preference/Earliest Available
Camila Kotrady, MA
Dianne DeCarolis, MA
Erin Moskun, MA
Tina Morrill, MA
Kat Delaney, LCMHC
Lauren Doyle, LICSW
Narell Sheets, MA
Christina Mangold, Intern
Elizabeth Duffy, MSN, PHMNP, AGPCNP
Please list 2-3 specific days and times within the next 2 weeks that you are available for an intake appointment.
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How Did You Hear About Us?
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