First Visit Intake Form

Call our Practice Manager on Tuesdays & Fridays from 8:30-4:30PM at 617-431-6140. 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? *


Please choose your payment option *

Private Pay (Check, Mastercard, Visa)BU Student Health PlanBlue Cross/Blue ShieldBlue Cross/Blue Shield - Out of State

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