Request an Appointment

Potential Client Name *

First

Last

Please share the name that appears on the clients insurance member ID card, or State ID.

Date of Birth *//

Please verify that this date is correct before moving to the next item. Make sure to change the year section from 2024.

Is this referral for a minor client? *

Is the identified client named above over 18 years old?

Is the youth 12 years or older? *

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? *

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? *

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 *

Do you have your EAP authorization already? *

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.

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? *

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? *

For possible in person sessions the location will determine clinicians available to you in later steps.

Clinician Gender Preference *

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 *

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? *

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? *

These sessions are only scheduled for remote telehealth sessions.

What In-Person (Face to Face) services are you seeking? *

These sessions are only scheduled for in-person face to face sessions in either the Dedham, MA or Lincoln, RI offices.

Session Frequency requested? *

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) *

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) *