New Client Profile Form

Client Information

Client First Name *

Client Last Name *

Preferred Name

Client Email Address *

Client Phone Number *

Preferred Method of Communication

Call

Text

State of Residence

Client Gender

Male

Female

Non-Binary or Transgender

Is the Client a Minor?

Yes

If client is school aged, what school district are they enrolled with?

If the client is 15 years of age or under, is there a custody agreement, court order, or restraining order regarding this child?

Yes

We will need a copy for your child’s file. Please Upload it here or email it to [email protected]

Please provide name and contact information of the child’s other parent/guardian, if applicable.

Guardian's First Name
Guardian's Last Name
Guardian's Email
Guardian's Phone Number

Date of Birth *

Age *

Other Pronouns

Pronouns

He/Him

She/Her

They/Them

Other

Contact Information (if different from client)

Contact's First Name

Contact's Last Name

Contact's Phone Number

Contact's Email

If you are contacting on behalf of the client, have they agreed to therapy?

Yes

I’m waiting to find a therapist before speaking with the client

Therapy is mandated by court of legal authority

Please Type Other Reason Here

Therapy Preferences (please choose all that apply)

Telehealth/Secure Therapy by Video (Anywhere in MA)

In Person in West Yarmouth.

In Person in Bourne

My preference for in person but I'm open to 100% telehealth if in person is not available

I ONLY wish to be seen in person

I am open to seeing a male or female therapist

I ONLY wish to be seen by a male therapist

I ONLY wish to be seen by a female therapist

I am requesting a specific therapist but am willing to see another

Therapist you are requesting to see:

Client's Availability for Sessions (choose all the apply) *

Please specify other time here

Please Specify Other Insurance here

Is there anything else you would like us to know at this time?

Would you like us to verify your insurance now?

Yes

Insurance Company Listed on Your Card

Member ID#

Plan (if you see it on your card)

Group Number (if you see it on your card)

First Name (EXACTLY as it appears on your card)

Middle Name or Initial (EXACTLY as it appears on our card)

Last Name (EXACTLY as it appears on your card)

Name and DOB of CARD HOLDER (if not self)

Upload a Picture of the Front of your Card (preferred but not necessary)

Upload a Picture of the Back of your Card (preferred but not necessary)

If you have any questions or issues completing this form, please contact Linda Gardner, Client Services Coordinator at [email protected] for assistance.