Request an Appointment

Please share the name that appears on the clients insurance member ID card, or State ID.
Please verify that this date is correct before moving to the next item. Make sure to change the year section from 2023.
Is the identified client named above over 18 years old?
Click or drag a file to this area to upload.
You can take a picture with your cellphone and upload it here.
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.
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.
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.
Selecting no preference for Gender will give the client the most possible options for assignment. This is the fastest of all of the choices.
For possible in person sessions the location will determine clinicians available to you in later steps.
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.
This helps us prevent offering you matches for a clinician that is already working with close matches.
Please explain your relation to the identified client at the start of this form.
What brings you to counseling at this time? Is there something specific, such as a particular event? Be as detailed as you can. This helps us decide which therapist is the most appropriate for you.
Please share the earliest time each day that you would be able to either come to the office or to start telehealth. ex: if you finish work at 4pm please put the earliest time at 4:30 to give yourself travel and or prep time for the session. The more specific you are the more likely you will be scheduled sooner. The more days and times given, the quicker you will be assigned.