First Visit Intake Form

    Call our Practice Manager on Monday-Friday from 8:30-4:30PM at 617-431-6140 or fax at 207-203-9586. You may leave a voicemail and we will call you back as soon as possible. You may also fill out our online intake form below which will be sent directly to us.

    **We do not treat anyone under the age of 14.**

    First Name *

    Last Name *

    Date of Birth *

    Home Address *

    City *

    State *

    Zipcode/Postcode *

    Email Address *

    Cell Phone Number *



    Best time to reach you? *

    ***Please note that the caller ID may not say our company name***

    May we leave a message at this number? *


    do you prefer telemedicine appointments Y or N? (Massachusetts only)

    Which location do you prefer to visit? *

    Please choose your payment option *

    Private Pay (Amex, Discover, Mastercard, Visa)BU Student Health PlanBlue Cross/Blue ShieldBlue Cross/Blue Shield - Out of StateTufts Commercial PTufts CommercialAetnaCignaOptumUnited Health Care (UHC)UMRHarvard PilgrimAlways
    ** We do not accept public or state versions of the following insurances: Mass Health **

    I would like assistance with the following concerns *

    Medication ManagementPsychiatric EvaluationDepressionStress ManagementADD/ADHDPTSDInsomniaAnxietyConduct DisorderSchizophrenia / Schizoaffective DisorderSubstance AbuseAddiction Disorder (Alcohol, Opiod, Internet, Sexual, Gambling, ect)Anger/ IrritabilityEating DisorderSleep DisorderBipolar DisorderBorderline Personality Disorder (BPD)Cutting and/or Self HarmI’m having suicidal thoughts, I’m feeling hopeless, I have thoughts of hurting myselfRecent In-Patient Psychiatric Hospital DischargeRecent Intensive Out Patient Program

    I have the following medical issues *

    HeadachesOther chronic painHigh Blood PressureCardiac ProblemsDiabetesNeurological ConditionBack or neck painObesityHigh CholesterolGastrointestinal ProblemsSleep Apnea or Other Sleep ProblemsAsthma/Respiratory ProblemsOtherI do not have any medical conditions

    List of Current Medications *

    Additional Details

    I understand that my first meeting with my provider is an opportunity to gather more information about my mental health care needs. If my provider feels she cannot treat my needs effectively and safely she will refer me to a mental health care practice who specializes in my condition.