Download Print Intake Form PDF

Please note that you will need your insurance information to complete this form. Please complete all
fields so that we may quickly and accurately identify the best clinician to meet your needs. Missing
information will delay your request. When completed, please fax to: (617) 259-1899.
First name: ___________________________________________
Last name: ____________________________________________
Zip code: _______________
Phone number: ______-______-________ ext. _____
Best time to reach you: ______________
May we leave a message at this number? Yes ____ No ____
May we contact you through email? Yes ____ No _____
If yes, your email address: ________________________________________
How did you hear about us or who referred you to us?
__ My Primary Care Doctor
__ Friend/Family Member
__ Internet search
__ NPR/Radio
__ Social Media
__ Another Mental Health Provider/Physician
__ Insurance Company website/staff
__ My college/school: ______________________
__ Newton TAB
__ Other: ________________________________
I’m interested in:
__ Individual Counseling
__ Neuropsychological Testing
__ Learning disability/Dyslexia testing
__ Health & Wellness Services
__ Transcranial Magnetic Stimulation (TMS) Therapy
__ Psychiatry & Medication Management
__ Couples Counseling
__ Psychological Testing/Therapeutic Assessment
__ Biofeedback & Stress Management Training
__ Career Assessment & Consulting
__ Child & Adolescent Services
We very rarely have evening appointments. Appointments are typically only available between 8am and
5pm.
Can you attend between 8am and 5pm? Yes ____ No ____
Please list specific days/times you are available: _________________________________________
Do you prefer to work with a: Man ____ Woman ____ No preference ____
Is there a specific clinician you are interested in working with? Name: ___________________________
I prefer services in:
__ Back Bay/Boston __ Newton Corner __ Newton-Wellesley __ Financial District/Downtown Boston
Insurance/Payment Type:
We regret that we are NOT able to accept the following insurances:
 MassHealth Plans (MBHP, Network Health, Neighborhood Health)
 Fallon Community Health Plan
 Tufts HMO
If you have one of these insurances, you may either pay privately or seek an alternative provider. Your
insurance company can help you locate a provider who accepts your insurance and we recommend
calling them directly for assistance.
Please choose your payment method from the following choices:
__ Private Pay (Cash, check, MasterCard, Visa)
__ Blue Cross Blue Shield of MA
__ HMO
__ POS
__ PPO
Policy/subscriber ID #: ______________________________
(including all letters)
Member suffix #: ______
__ Blue Cross from another state
Which state: ______________
__ Harvard Pilgrim
__ HMO
__ POS
__ PPO
Policy/subscriber ID #: ______________________________
(including all letters)
Member suffix #: ______
__ United Behavioral Health
__ United Healthcare
__ United Healthcare Student Resources
__ Aetna
__ PPO
__ Aetna Student Health Plan
__Medicare
__ Oxford Health Plan
__ Beacon Health Strategies – GIC
__ Tufts Navigator – GIC
__ UMR
__ Other Name of plan: _______________________________
I would like assistance with the following concerns:
(Check all that apply)
__ Depression
__ Relationship issues
__ Adjustment to medical issues
__ ADD/ADHD
__ LGBTQ issues
__ Parenting Guidance
__ Other
__ Anxiety
__ Sexuality
__ Improving health
__ Memory/cognitive problems
__ Cultural issues
__ Anger
Please describe:
__ Stress Management
__ Grief or loss
__ Substance abuse
__ Trauma
__ Life transitions
__ Insomnia/Sleep problems
I have the following medical issues:
(Check all that apply)
__ Headaches
__ Gastrointestinal problems
__ High blood pressure
__ Respiratory problems
__ Sleep apnea
__ Asthma
__ Neurological condition:
__Concussion/brain injury
__ Back or neck pain
__ Reproductive problems
__ High cholesterol
__ Insomnia or sleep problems
__ Endocrine/thyroid
__ No medical conditions
__ MS
__ Lyme disease
__ Other chronic pain
__Diabetes
__ Cardiac problems
__ Obesity
__ Menopausal problems
__ Other: __________________
__ Seizures
__ Memory disorder/Alzheimer’s
PLEASE FAX THIS FORM TO 617-259-1899