New Client Initial Contact Form

Contact Type

Fax

Phone

Text

Call Type and Direction:

Client is on the Phone NOW

I am Returning a Client's Voicemail or Email/Text request for a Call

I am Calling the Client (First Contact) based on a referral

Specify Others

Client First Name *

Client Last Name *

Preferred Name

Client Email Address *

Client Phone Number *

Date of birth *

Age *

Client Gender

Male

Female

Non-Binary or Transgender

Respond To Text By

Phone

Text

Please Specify Other Insurance here

Is the Client a Minor?

Yes

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

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

Therapy Preferences

Telehealth/Secure Therapy by Video (Anywhere in MA)

In Person in Yarmouth Port (waitlist only)

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:

Please Type Other Reason Here

Client's Availability for Sessions

Please Specify Other Time Here

Anything else we should know?

Would you like us to verify your insurance and copay now?

Yes

The 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)

What was the Fax Origin?

Primary Care Doctor

Insurance Company

Other

Specify Other Fax Origin

Upload mFax PDF File

Specify Other Email Contact Source

Reason for Declining Client

Insurance Not Taken

Insurance Not Taken but include information on Out of Network Benefits

Requesting Family Therapy

Requesting Marriage Counseling/Couples Therapy

Other

Specify Other Reason of Declining Client

Original Contact Notes