Name * First Name Last Name What are you pronouns? * Date of Birth * MM DD YYYY Phone * (###) ### #### Email * What are you looking for? * Individual Counseling Family Counseling Couple Counseling Youth Counseling Child/Parent Counseling EMDR Therapy What is the reason for seeking therapy today? * Anxiety/Panic Depression ADHD/ADD Trauma/PTSD Bipolar Stress Related Disorder Substance Use Disorder Grief/Bereavement Personality Disorder Suicide/Self-harm OCD Other Psychological issues Appointment Date Request * When would you like to be seen? MM DD YYYY What are the appointment times you are looking for? * Please specify the time frame. Location of Services * In Person Session: 3-6 months Waitlist (office located in Medway MA) Telehealth Which provider would like to work with? * Margela (in-person only Saturdays) Siedah (Telehealth only) Giannah (Telehealth only) Insurance * Please select insurance plan BlueCross BlueShield Optum United Behavioral Health Havard Pilgrim Health Plan Inc. UMR Always health Partners Cigna Aetna Oscar Health Tufts (Unify Plans, Connector Plans, MassHealth Plans) Oxford Other Who is the insurance carrier? * Please select insurance carrier. Select an option Self Spouse Parent Other Insurance carrier information * Please provide the plan's carrier: Full Name & Date of birth. What is your presenting problem? * List three goals you would like to work on in therapy. Your request will be reviewed, and the intake coordinator will reach out. Thank you!
