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Appointment Type
*
Teletherapy
In Office (Limited)
Name
*
First
Last
Email
*
Phone Number
*
Please check the box indicating your preferred method of payment, check all boxes that apply
Private Pay
Blue Cross
Harvard Pilgrim
Tufts
Aetna
Other
Other (please indicate)
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Other Payment Method
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Is your insurance a "PPO"?
*
Yes
No
(This means that we can see you regardless of whether our practice accepts your insurance or not.)
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Please see your insurance card for the following question, Do you have a deductible
Yes
No
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If yes, how much is it?
$500
$1,000
$1,500
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Has your deductible been met this year already?
Yes
No
Not Sure
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I am available to make an appointment on: (check all that apply)
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
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Can you make early morning weekday sessions? If yes, beginning at
7am
8am
9am
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Can you make weekend appointments? If yes
Only Saturday
Only Sunday
Either day could work
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Therapist Preference
*
Female Therapist
Male Therapist
First Available
No Preference
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Preferred Appointment Time
Morning
Afternoon
Evening
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Can you make weekday appointments that begin from 10am-3pm?
*
Yes
No
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Our private pay rate is $165. On a limited basis we can consider a reduction in rate of between 10-25% depending on circumstances. If insurance coverage is not available or desirable to you, can you pursue private pay care?
Yes
No
Message - Please tell us how we can help
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How did you hear about us?
My own web search
From a trusted person
From a Referral source such as Doctor, Counselor Hospital or Health Center
If Referral, please specify
Other
If Other, Please specify
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Other (please indicate)
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Referrer (please specify)
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