Request an Appointment
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Request an Appointment
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Potential Client Name
*
First
Last
Please share the name that appears on the clients insurance member ID card, or State ID.
Does client have alternate preferred name?
*
Select
No
Yes
Does the client have a name that they prefer to be called other than the legal name listed above?
Please share preferred name.
*
Enter the name that the client uses instead of the legal name listed above.
Date of Birth
*
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Please verify that this date is correct before moving to the next item. Make sure to change the year section from 2024.
Any Preferred pronouns?
He/Him/His
She/Her/Hers
They/Them/Theirs
Ze/Zir/Zirs
Does the client have any specific pronouns they are most comfortable with. Answering this section is optional as you only should complete it if your comfortable.
Is this referral for a minor client?
*
Please Choose
No
Yes
Is the identified client named above over 18 years old?
Is the youth 12 years or older?
*
Please Choose
No
Yes
Telehealth is not available for youth under 12 years old. Youth under 12 can not participate in telehealth, and will have to select in-person psychotherapy sessions.
Whats the youths motivation level for therapy?
Selected Value:
1
Share their rating of possible engagement and motivation for therapy. Please understand that low motivation for therapy will possibly result in a quick transition if the youth does not engage with clinician.
Caregiver Name
*
First
Last
Who is the caregiver responsible for the youth?
Email
*
Email
Confirm Email
Phone
*
Upload picture of State ID / Drivers License for the person responsible for payment
Click or drag a file to this area to upload.
You can take a picture with your cellphone and upload it here.
Were you directed to us by an Insurance company or advocate?
*
Please Choose
No
Yes
Select yes if you were told about a specific opening or you have a case or referral number.
Do you have a Referral or Case ID number?
*
Please Choose
No
Yes
Some insurances or referral providers will provide you with a case ID or other number. If you have one this can increase the chances of getting assigned quicker.
What is the Case # or Referral ID?
Please share the number above exactly as it was sent to you. This helps us match the information we may have already received.
Method of Payment
*
Please select choice.
(Private Pay) Cash
Aetna
Auxiant
BeneMax
Blue Cross Blue Shield Insurance
Carelon Behavioral Health
EAP (from ANY Insurance / Company)
Evernorth (Cigna)
Fallon Healthcare (MassHealth)
Harvard Pilgrim Insurance
Health Plans Inc
Modern Assistance Program
Community Care Cooperative (MassHealth)
Mass General Brigham Health Plan (Commercial)
Mass General Brigham Health Plan (MassHealth)
MBHP (MassHealth)
Tufts Health Plan (Commercial)
Tufts Health Public (MassHealth)
Unicare
United Healthcare
WellSense Health Plan (Commercial)
WellSense Health Plan (MassHealth)
Do you have your EAP authorization already?
*
Please select choice.
No
Yes
The EAP benefits you use before accessing your insurance. In order to use the services the right way, you must request the authorization before starting treatment. Have you done this already? If no, we can give instructions on how to do this.
What Insurance is the EAP through?
*
Please share with us if it is KGA, Cigna, AETNA, Workforce, Tufts or any other EAP provider.
EAP Authorization Number
*
To use your EAP benefit you will have to ask for an authorization. Please provide that authorization here.
Primary Insurance Member ID / MassHealth #
*
If you have commercial insurance please share the member ID here. If you have MassHealth please share both the masshealth number as well as the Member ID for the type of MassHealth you have. This would be two separate member numbers.
Is the client covered by any additional insurances?
*
Yes
No
Upload Picture of Insurance card
Click or drag a file to this area to upload.
Please upload a picture of the ID card if you have it. You can use a cellphone to take the picture and email it to yourself for upload here if needed.
What is the second Insurance?
*
Please select choice.
Aetna
Auxiant
BeneMax
Blue Cross Blue Shield Insurance
Carelon Behavioral Health
EAP (from ANY Insurance / Company)
Evernorth (Cigna)
Fallon Healthcare (MassHealth)
Harvard Pilgrim Insurance
Health Plans Inc
Modern Assistance Program
Community Care Cooperative (MassHealth)
Mass General Brigham Health Plan (Commercial)
Mass General Brigham Health Plan (MassHealth)
MBHP (MassHealth)
Tufts Health Plan (Commercial)
Tufts Health Public (MassHealth)
Unicare
United Behavioral Health
United Healthcare
WellSense Health Plan (Commercial)
WellSense Health Plan (MassHealth)
Secondary Insurance Member ID / MassHealth #
*
If you have commercial insurance please share the member ID here. If you have MassHealth please share both the masshealth number as well as the Member ID for the type of MassHealth you have. This would be two separate member numbers.
Insurance 2 Picture
Click or drag a file to this area to upload.
Which GENNEW Location is closest to your home address?
*
Please Choose
Dedham, Massachusetts
Medway, Massachusetts
Lincoln, Rhode Island
For possible in person sessions the location will determine clinicians available to you in later steps.
Clinician Gender Preference
*
Please Choose
Any Clinician, No gender preference (Fastest)
Any Male Clinician (Faster)
Any Female Clinician
Selecting no preference for Gender will give the client the most possible options for assignment. This is the fastest of all of the choices.
Service Delivery Preference
*
How would you like to participate in therapy?
Telehealth Only - (Remote Therapy) (Faster)
Telehealth or In-Person (No Preference) (Fastest)
In Person Only - (Face to Face)
Please know that we have different providers for different services. Due to the pandemic the in person services are less available while telehealth options are more flexible and expansive at the moment.
What (No Preference) services are you seeking?
*
Select Service
Individual Therapy
Couples Therapy
Family Therapy
LICSW / LMHC Licensure Supervision
These sessions could be scheduled for in person or telehealth, whichever is available first. This is the fastest assignment selection as it gives the most options.
What Telehealth (Remote) services are you seeking?
*
Select Service
Individual Therapy
Couples Therapy
Family Therapy
LICSW / LMHC Licensure Supervision
These sessions are only scheduled for remote telehealth sessions.
What In-Person (Face to Face) services are you seeking?
*
Select Service
Couples Therapy
Family Therapy
Individual Therapy
LICSW / LMHC Licensure Supervision
These sessions are only scheduled for in-person face to face sessions in either the Dedham, MA or Lincoln, RI offices.
Session Frequency requested?
*
How often would you like sessions?
Any Frequency
Weekly Sessions
Bi-Weekly Sessions
Weekly sessions are the traditional start. This is one session every 7 days. = 4 sessions a month. Biweekly is a reduced frequency being one session every 2 weeks. = 2 sessions a month Monthly is a reduced frequency being one session every 4 weeks. = 1 session a month
1st Choice of Clinician (M/F) (No Preference)
*
Select the Therapist you want most.
(Fastest) First available M/F Clinician
(Faster) Amanda Carroll, LCSW
(Faster) Carolyn Gallagher, LCSW
(Faster) Cindy Jean-Georges
(Faster) Kelly DoSouto
(Faster) Myveca Saint Vil Pimentel
(Faster) Rachael Burum
(Faster) Robin Bleicher
(Faster) Rong Tan
(Fast) Hannah Rogers
(Fast) Isoken Osazee, LCSW
(Fast) Ilana Goldberg
Bernadette Moitt, LCSW
Chris Blanco-Ramos, LMHCA
Dariana Quinones, LICSW, PMH-C
Elana Pijanowski
Elizabeth Smith, LCSW
Faye Justynski
Kendra Lisenby
(Back in office 06/23/2025) Samantha Leong, LCSW
(Back in office 09/01/2025) Stephanie Jean-Louise
Tara Hagopian, LICSW
Val Lutkevich, LCSW
(Waitlist) Elliette Utset
(Waitlist) Jessica Furtado, LCSW
(Waitlist) Nicholas Casali, LICSW
These clinicians may be in-person or telehealth, whichever is available first. Some clinicians in this list will practice both remote and in person, while others may be telehealth only. If undecided on a therapist, it is suggested that you choose (Any M/F Clinician) as it is the fastest option in assigning a client.
2nd Choice of Clinician (M/F) (No Preference)
*
Who else would you work with?
(Fastest) First available M/F Clinician
(Faster) Amanda Carroll, LCSW
(Faster) Carolyn Gallagher, LCSW
(Faster) Cindy Jean-Georges
(Faster) Kelly DoSouto
(Faster) Myveca Saint Vil Pimentel
(Faster) Rachael Burum
(Faster) Robin Bleicher
(Faster) Rong Tan
(Fast) Hannah Rogers
(Fast) Isoken Osazee, LCSW
(Fast) Ilana Goldberg
Bernadette Moitt, LCSW
Chris Blanco-Ramos, LMHCA
Dariana Quinones, LICSW, PMH-C
Elana Pijanowski
Elizabeth Smith, LCSW
Faye Justynski
Kendra Lisenby
(Back in office 06/23/2025) Samantha Leong, LCSW
(Back in office 09/01/2025) Stephanie Jean-Louise
Tara Hagopian, LICSW
Val Lutkevich, LCSW
(Waitlist) Elliette Utset
(Waitlist) Jessica Furtado, LCSW
(Waitlist) Nicholas Casali, LICSW
If the first isn't available, please pick who else you would consider. Selecting Any Clinician option will give the most options if you are undecided.
1st Choice of Clinician (Male) (IP/Telehealth)
*
Select the Therapist you want most.
(Fastest) First available Male Clinician
Chris Blanco Ramos, LMHCA
(Waitlist) Nicholas Casali, LICSW
These clinicians may be in-person or telehealth, whichever is available first. Some clinicians in this list will practice both remote and in person, while others may be telehealth only. If undecided on a therapist, it is suggested that you choose (Any Male Clinician) as it is the fastest option in assigning a client.
2nd Choice of Clinician (Male) (IP/Telehealth)
*
Who else would you work with?
(Fastest) First available Male Clinician
Chris Blanco Ramos, LMHCA
(Waitlist) Nicholas Casali, LICSW
If the first isn't available, please pick who else you would consider. Selecting Any Clinician option will give the most options if you are undecided.
1st Choice of Clinician (Female) (IP/Telehealth)
*
Select the Therapist you want most.
(Fastest) First available Female Clinician
(Faster) Amanda Carroll, LCSW
(Faster) Carolyn Gallagher, LCSW
(Faster) Cindy Jean-Georges
(Faster) Kelly DoSouto
(Faster) Myveca Saint Vil Pimentel
(Faster) Rachael Burum
(Faster) Robin Bleicher
(Faster) Rong Tan
(Fast) Hannah Rogers
(Fast) Isoken Osazee, LCSW
(Fast) Ilana Goldberg
Bernadette Moitt, LCSW
Dariana Quinones, LICSW, PMH-C
Elana Pijanowski
Elizabeth Smith, LCSW
Faye Justynski
Kendra Lisenby
(Back in office 06/23/2025) Samantha Leong, LCSW
(Back in office 09/01/2025) Stephanie Jean-Louise
Tara Hagopian, LICSW
Val Lutkevich, LCSW
(Waitlist) Elliette Utset
(Waitlist) Jessica Furtado, LCSW
These clinicians may be in-person or telehealth, whichever is available first. Some clinicians in this list will practice both remote and in person, while others may be telehealth only. If undecided on a therapist, it is suggested that you choose (Any Female Clinician) as it is the fastest option in assigning a client.
2nd Choice of Clinician (Female) (IP/Telehealth)
*
Select the Therapist you want most.
(Fastest) First available Female Clinician
(Faster) Amanda Carroll, LCSW
(Faster) Carolyn Gallagher, LCSW
(Faster) Cindy Jean-Georges
(Faster) Kelly DoSouto
(Faster) Myveca Saint Vil Pimentel
(Faster) Rachael Burum
(Faster) Robin Bleicher
(Faster) Rong Tan
(Fast) Hannah Rogers
(Fast) Isoken Osazee, LCSW
(Fast) Ilana Goldberg
Bernadette Moitt, LCSW
Dariana Quinones, LICSW, PMH-C
Elana Pijanowski
Elizabeth Smith, LCSW
Faye Justynski
Kendra Lisenby
(Back in office 06/23/2025) Samantha Leong, LCSW
(Back in office 09/01/2025) Stephanie Jean-Louise
Tara Hagopian, LICSW
Val Lutkevich, LCSW
(Waitlist) Elliette Utset
(Waitlist) Jessica Furtado, LCSW
If the first isn't available, please pick who else you would consider. Selecting Any Clinician option will give the most options if you are undecided.
1st Choice of Clinician (M/F) (Dedham, MA)
*
Select the Therapist you want most.
(Fastest) First available M/F Clinician
(Faster) Kelly DoSouto
(Faster) Rachael Burum
(Faster) Robin Bleicher
(Faster) Rong Tan
(Fast) Isoken Osazee, LCSW
(Fast) Ilana Goldberg
Bernadette Moitt, LCSW
Elana Pijanowski
Faye Justynski
Kendra Lisenby
(Back in office 09/01/2025) Stephanie Jean-Louise
Val Lutkevich, LCSW
(Waitlist) Jessica Furtado, LCSW
These clinicians have In-Person availability in Dedham, Ma office. If you are unsure of exactly who you would like to work with, please select (Any Clinician Available) as that is the fastest assignment option.
2nd Choice of Clinician (M/F) (Dedham, MA)
*
Who else would you work with?
(Fastest) First available M/F Clinician
(Faster) Kelly DoSouto
(Faster) Rachael Burum
(Faster) Robin Bleicher
(Faster) Rong Tan
(Fast) Isoken Osazee, LCSW
(Fast) Ilana Goldberg
Bernadette Moitt, LCSW
Elana Pijanowski
Faye Justynski
Kendra Lisenby
(Back in office 09/01/2025) Stephanie Jean-Louise
Val Lutkevich, LCSW
(Waitlist) Jessica Furtado, LCSW
If the first isn't available, please pick who else you would consider. Selecting Any Clinician option will give the most options if you are undecided.
1st Choice of Clinician (Male) (Dedham, MA)
*
Select the Therapist you want most.
No Male Dedham Clinicians Available
These male clinicians have In-Person availability in Dedham, Ma office. If you are unsure of exactly who you would like to work with, please select (Any Male Clinician Available) as that is the fastest assignment option.
2nd Choice of Clinician (Male) (Dedham, MA)
*
Who else would you work with?
No male DEDHAM clinicians available
If the first isn't available, please pick who else you would consider. Selecting Any Clinician option will give the most options if you are undecided.
1st Choice of Clinician (Female) (Dedham, MA)
*
Select the Therapist you want most.
(Fastest) First available Female Clinician
(Faster) Kelly DoSouto
(Faster) Rachael Burum
(Faster) Robin Bleicher
(Faster) Rong Tan
(Fast) Isoken Osazee, LCSW
(Fast) Ilana Goldberg
Bernadette Moitt, LCSW
Elana Pijanowski
Faye Justynski
Kendra Lisenby
(Back in office 09/01/2025) Stephanie Jean-Louise
Val Lutkevich, LCSW
(Waitlist) Jessica Furtado, LCSW
These female clinicians have In-Person availability in Dedham, Ma office. If you are unsure of exactly who you would like to work with, please select (Any Female Clinician Available) as that is the fastest assignment option.
2nd Choice of Clinician (Female) (Dedham, MA)
*
Who else would you work with?
(Fastest) First available Female Clinician
(Faster) Kelly DoSouto
(Faster) Rachael Burum
(Faster) Robin Bleicher
(Faster) Rong Tan
(Fast) Isoken Osazee, LCSW
(Fast) Ilana Goldberg
Bernadette Moitt, LCSW
Elana Pijanowski
Faye Justynski
Kendra Lisenby
(Back in office 09/01/2025) Stephanie Jean-Louise
Val Lutkevich, LCSW
(Waitlist) Jessica Furtado, LCSW
If the first isn't available, please pick who else you would consider. Selecting Any Clinician option will give the most options if you are undecided.
1st Choice of Clinician (M/F) (Medway, MA)
*
Select the Therapist you want most.
(Fastest) First available M/F Clinician
(Faster) Carolyn Gallagher, LCSW
(Fast) Hannah Rogers
(Waitlist) Nicholas Casali, LICSW
These clinicians have In-Person availability in Medway, MA. If you are unsure of exactly who you would like to work with, please select (Any Clinician Available) as that is the fastest assignment option.
2nd Choice of Clinician (M/F) (Medway, MA)
*
Who else would you work with?
(Fastest) First available M/F Clinician
(Faster) Carolyn Gallagher, LCSW
(Fast) Hannah Rogers
(Waitlist) Nicholas Casali, LICSW
If the first isn't available, please pick who else you would consider. Selecting Any Clinician option will give the most options if you are undecided.
1st Choice of Clinician (Male) (Medway, MA)
*
Select the Therapist you want most.
(Extended Wait) Nicholas Casali, LICSW
These clinicians have In-Person availability in Medway, MA office. If you are unsure of exactly who you would like to work with, please select (Any Clinician Male Available) as that is the fastest assignment option.
2nd Choice of Clinician (Male) (Medway, MA)
*
Select the Therapist you want most.
(Fastest) Any Male Clinician
If the first isn't available, please pick who else you would consider. Selecting Any Clinician option will give the most options if you are undecided.
1st Choice of Clinician (Female) (Medway, MA)
*
Select the Therapist you want most.
(Fastest) Any Female Clinician
(Faster) Carolyn Gallagher, LCSW
(Fast) Hannah Rogers
These clinicians have In-Person availability in Medway, MA office. If you are unsure of exactly who you would like to work with, please select (Any Clinician Female Available) as that is the fastest assignment option.
2nd Choice of Clinician (Female) (Medway, MA)
*
Select the Therapist you want most.
(Fastest) Any Female Clinician
(Faster) Carolyn Gallagher, LCSW
(Fast) Hannah Rogers
If the first isn't available, please pick who else you would consider. Selecting Any Clinician option will give the most options if you are undecided.
1st Choice of Clinician (M/F) (Lincoln, RI)
*
Select the Therapist you want most.
(Fastest) First available M/F Clinician
(Faster) Amanda Carroll, LCSW
(Faster) Cindy Jean-Georges
Chris Blanco-Ramos, LMHCA
These clinicians have In-Person availability in Lincoln, RI office. If you are unsure of exactly who you would like to work with, please select (Any Clinician Available) as that is the fastest assignment option.
2nd Choice of Clinician (M/F) (Lincoln, RI)
*
Who else would you work with?
(Fastest) First available M/F Clinician
(Faster) Amanda Carroll, LCSW
(Faster) Cindy Jean-Georges
Chris Blanco-Ramos, LMHCA
If the first isn't available, please pick who else you would consider. Selecting Any Clinician option will give the most options if you are undecided.
1st Choice of Clinician (Male) (Lincoln, RI)
*
Select the Therapist you want most.
Chris Blanco-Ramos, LMHCA
These clinicians have In-Person availability in Lincoln, RI office. If you are unsure of exactly who you would like to work with, please select (Any Clinician Male Available) as that is the fastest assignment option.
2nd Choice of Clinician (Male) (Lincoln, RI)
*
Select the Therapist you want most.
Chris Blanco-Ramos, LMHCA
If the first isn't available, please pick who else you would consider. Selecting Any Clinician option will give the most options if you are undecided.
1st Choice of Clinician (Female) (Lincoln, RI)
*
Select the Therapist you want most.
(Fastest) Any Female Clinician In-Person (Lincoln)
(Faster) Amanda Carroll, LCSW
(Fast) Cindy Jean-Georges
These clinicians have In-Person availability in Lincoln, RI office. If you are unsure of exactly who you would like to work with, please select (Any Clinician Female Available) as that is the fastest assignment option.
2nd Choice of Clinician (Female) (Lincoln, RI)
*
Select the Therapist you want most.
(Fastest) Any Female Clinician In-Person (Lincoln)
(Faster) Amanda Carroll, LCSW
(Fast) Cindy Jean-Georges
If the first isn't available, please pick who else you would consider. Selecting Any Clinician option will give the most options if you are undecided.
1st Choice of Clinician (M/F) (Telehealth)
*
Select the Therapist you want most.
(Fastest) First available M/F Clinician
(Faster) Amanda Carroll, LCSW
(Faster) Carolyn Gallagher, LCSW
(Faster) Cindy Jean-Georges
(Faster) Kelly DoSouto
(Faster) Myveca Saint Vil Pimentel
(Faster) Rachael Burum
(Faster) Robin Bleicher
(Faster) Rong Tan
(Fast) Hannah Rogers
(Fast) Isoken Osazee, LCSW
(Fast) Ilana Goldberg
Bernadette Moitt, LCSW
Chris Blanco-Ramos, LMHCA
Dariana Quinones, LICSW, PMH-C
Elana Pijanowski
Elizabeth Smith, LCSW
Faye Justynski
Kendra Lisenby
(Back in office 06/23/2025) Samantha Leong, LCSW
(Back in office 09/01/2025) Stephanie Jean-Louise
Tara Hagopian, LICSW
Val Lutkevich, LCSW
(Waitlist) Elliette Utset
(Waitlist) Jessica Furtado, LCSW
(Waitlist) Nicholas Casali, LICSW
These clinicians have remote telehealth availability only. If you are unsure of exactly who you would like to work with, please select (Any M/F Clinician Available) as that is the fastest assignment option.
2nd Choice of Clinician (M/F) (Telehealth)
*
Who else would you work with?
(Fastest) First available M/F Clinician
(Faster) Amanda Carroll, LCSW
(Faster) Carolyn Gallagher, LCSW
(Faster) Cindy Jean-Georges
(Faster) Kelly DoSouto
(Faster) Myveca Saint Vil Pimentel
(Faster) Rachael Burum
(Faster) Robin Bleicher
(Faster) Rong Tan
(Fast) Hannah Rogers
(Fast) Isoken Osazee, LCSW
(Fast) Ilana Goldberg
Bernadette Moitt, LCSW
Chris Blanco-Ramos, LMHCA
Dariana Quinones, LICSW, PMH-C
Elana Pijanowski
Elizabeth Smith, LCSW
Faye Justynski
Kendra Lisenby
(Back in office 06/23/2025) Samantha Leong, LCSW
(Back in office 09/01/2025) Stephanie Jean-Louise
Tara Hagopian, LICSW
Val Lutkevich, LCSW
(Waitlist) Elliette Utset
(Waitlist) Jessica Furtado, LCSW
(Waitlist) Nicholas Casali, LICSW
If the first isn't available, please pick who else you would consider. Selecting Any Clinician option will give the most options if you are undecided.
1st Choice of Clinician (Male) (Telehealth)
*
Select the Therapist you want most.
(Fastest) First available Male Clinician
Chris Blanco-Ramos, LMHCA
(Waitlist) Nicholas Casali, LICSW
These clinicians have remote telehealth availability only. If you are unsure of exactly who you would like to work with, please select (Any Male Clinician Available) as that is the fastest assignment option.
2nd Choice of Clinician (Male) (Telehealth)
*
Select the Therapist you want most.
(Fastest) First available Male Clinician
Chris Blanco-Ramos, LMHCA
(Waitlist) Nicholas Casali, LICSW
These clinicians have remote telehealth availability only. If you are unsure of exactly who you would like to work with, please select (Any Male Clinician Available) as that is the fastest assignment option.
1st Choice of Clinician (Female) (Telehealth)
*
Select the Therapist you want most.
(Fastest) First available Female Clinician
(Faster) Amanda Carroll, LCSW
(Faster) Carolyn Gallagher, LCSW
(Faster) Cindy Jean-Georges
(Faster) Kelly DoSouto
(Faster) Myveca Saint Vil Pimentel
(Faster) Rachael Burum
(Faster) Robin Bleicher
(Faster) Rong Tan
(Fast) Hannah Rogers
(Fast) Isoken Osazee, LCSW
(Fast) Ilana Goldberg
Bernadette Moitt, LCSW
Dariana Quinones, LICSW, PMH-C
Elana Pijanowski
Elizabeth Smith, LCSW
Faye Justynski
Kendra Lisenby
(Back in office 06/23/2025) Samantha Leong, LCSW
(Back in office 09/01/2025) Stephanie Jean-Louise
Tara Hagopian, LICSW
Val Lutkevich, LCSW
(Waitlist) Elliette Utset
(Waitlist) Jessica Furtado, LCSW
These clinicians have remote telehealth availability only. If you are unsure of exactly who you would like to work with, please select (Any Female Clinician Available) as that is the fastest assignment option.
2nd Choice of Clinician (Female) (Telehealth)
*
Who else would you work with?
(Fastest) First available Female Clinician
(Faster) Amanda Carroll, LCSW
(Faster) Carolyn Gallagher, LCSW
(Faster) Cindy Jean-Georges
(Faster) Kelly DoSouto
(Faster) Myveca Saint Vil Pimentel
(Faster) Rachael Burum
(Faster) Robin Bleicher
(Faster) Rong Tan
(Fast) Hannah Rogers
(Fast) Isoken Osazee, LCSW
(Fast) Ilana Goldberg
Bernadette Moitt, LCSW
Dariana Quinones, LICSW, PMH-C
Elana Pijanowski
Elizabeth Smith, LCSW
Faye Justynski
Kendra Lisenby
(Back in office 06/23/2025) Samantha Leong, LCSW
(Back in office 09/01/2025) Stephanie Jean-Louise
Tara Hagopian, LICSW
Val Lutkevich, LCSW
(Waitlist) Elliette Utset
(Waitlist) Jessica Furtado, LCSW
These clinicians have remote telehealth availability only. If you are unsure of exactly who you would like to work with, please select (Any Female Clinician Available) as that is the fastest assignment option.
Has the partner agreed to also participate in therapy?
*
Yes
No
Does the partner have insurance of any kind?
*
Yes
No
This helps us create a complete file that will register both participants and utilize insurance that is the lowest cost to the family.
Partners Insurance Member ID
*
Partners Insurance card
Click or drag a file to this area to upload.
Please upload a picture of the ID card if you have it. You can use a cellphone to take the picture and email it to yourself for upload here if needed.
Partners Date of Birth
*
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Please verify that this date is correct before moving to the next item. Make sure to change the year section from 2024.
What is the partners motivation level for participating in couples therapy?
Selected Value:
1
Share their rating of possible engagement and motivation for therapy.
Partners Name
*
First
Last
Who will be participating in couples therapy with you?
Partners Cell Number
*
We would also need to contact the other participant.
Partners email
*
Email
Confirm Email
So that we can share the appointment information with them as well.
Do you know of any relatives or friends who are currently receiving services at GENNEW?
*
Select Choice
No
Yes
This helps us prevent offering you matches for a clinician that is already working with close matches.
What is the persons name?
*
Please let us know the name of the person who is currently at GENNEW.
Please select all of the following which pertain to the client.
Addiction - Pornography
Addiction - Substances
Feeling - Anxiety
Feeling - Depression
Feeling - Guilt / Shame
Feeling - Obsessive or Intrusive Thoughts
Feeling - Violent of Aggressive behaviors
Feeling - Unhealthy Relationship with Food
Currently - Taking prescribed medication for symptoms
Previous / Current - Department of Youth Services
Previous / Current - Discharged from program or Hospital
Previous / Current - Homelessness
Previous / Current - Issues with the law
Previous / Current - Mental Health diagnosis formally diagnosed
Previous / Current - Suicide Ideation
Previous / Current - Suicide Attempts
Previous / Current - Therapy with another provider
What medication? Please add frequency and dosages.
*
Please share all medications currently prescribed to the identified client.
What provider made the formal diagnosis?
*
What was the diagnosis?
*
How recent was the last suicide attempt?
*
How recent were the Suicidal Thoughts?
*
Please share the frequency and the last time to help us understand the situation better.
Previous therapist name and last session date?
*
This helps us understand how long you have been out of therapy.
Reason for therapist transition?
*
Can you share why you are no longer with the previous therapist as detailed as possible.
What is the name of the program or hospital?
*
When is/was the discharge date from program or hospital?
*
Who are you completing this referral for?
*
Please Choose
Myself
My Client
My Child
My Family Member
My Friend
Please explain your relation to the identified client at the start of this form.
Referrer Name
*
First
Last
Referrer Email
*
Email
Confirm Email
Referrer Phone
*
Which Days are you available for Sessions?
*
Available all days
Any Weekday (Mon-Fri)
Weekends (Sat & Sun)
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Share what days of the week you can participate in a scheduled session consistently. The sessions will be 40-50 minutes
Which Times are you available for Sessions?
*
Morning (8am-12pm)
Afternoon (12pm - 4pm)
Evening (4pm - 8pm)
Anytime Available (8am-8pm)
We will try our best to send matches that are within these selections. The more availability you have the more matches that are possible.
What time does the youth get home from school?
*
This helps us schedule accordingly. Please don't share when is dismissal, but the earliest time the youth could consistently participate via in-person or remote telehealth.
Earliest start time for sessions?
*
Please specify on each day selected the earliest and latest you can participate in sessions. This helps us determine better matches for you. Please consider after school activities or work related obligations.
What is the presenting problem?
*
What brings you to counseling at this time? How long has it been happening? is there anything that we should know before scheduling? Be as detailed as you can. This helps us decide which therapist is the most appropriate for you.
Submit the referral form