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Request an Appointment
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Potential Client Name
*
First
Last
Date of Birth
*
Please verify that this date is correct before moving to the next item. Make sure to change the year from 2022
Is the client a minor?
*
Please Choose
No
Yes
How open is the youth to receiving therapy?
Selected Value:
1
Share their rating of possible engagement and motivation for therapy.
Caregiver Name
*
First
Last
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.
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)
Harvard Pilgrim Insurance
Health Plans Inc
Mass General Brigham Health Plan
Modern Assistance Program
MassHealth Community Care Cooperative
MassHealth MBHP
MassHealth Fallon Healthcare
MassHealth Mass General Brigham Health Plan
Masshealth Steward Health Choice
Masshealth Tufts Health Public
Masshealth WellSense Health Plan
Tufts Health Plan Commercial
Unicare
United Behavioral Health
United Healthcare
WellSense Health Plan Commercial
Insurance # / Member ID / Masshealth #
*
EAP Services requested 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.
EAP Authorization Number
*
To use your EAP benefit you will have to ask for an authorization. Please provide that authorization here.
Upload Picture of Insurance card
Click or drag a file to this area to upload.
Is the client covered by any additional insurances?
*
Yes
No
What is the second insurance?
*
Please select choice.
(Private Pay) Cash
Aetna
Auxiant
BeneMax
Blue Cross Blue Shield Insurance
Carelon Behavioral Health
EAP (from ANY Insurance / Company)
Evernorth (Cigna)
Harvard Pilgrim Insurance
Health Plans Inc
Mass General Brigham Health Plan
Modern Assistance Program
MassHealth Community Care Cooperative
MassHealth MBHP
MassHealth Fallon Healthcare
MassHealth Mass General Brigham Health Plan
Masshealth Steward Health Choice
Masshealth Tufts Health Public
Masshealth WellSense Health Plan
Tufts Health Plan Commercial
Unicare
United Behavioral Health
United Healthcare
WellSense Health Plan Commercial
Insurance # / Member ID / Masshealth # (copy)
*
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
Lincoln, Rhode Island
To better assign you to a clinician.
Clinician Preference
*
Please Choose
Any Clinician, No racial Preference, (Fastest)
Any Female Clinician (no racial preference) (Faster)
Any Male Clinician (no racial preference) (Faster)
Any Clinician of color (non-white preference) (Faster)
Asian Female Clinician
Any Black Clinician (M/F)
Black Female Clinician
Black Male Clinician
Any LatinX Clinician (M/F)
LatinX Female Clinician
LatinX Male Clinician
White Clinician (M/F)
White Female Clinician
White Male Clinician
Selecting any option that mentions no preference will always be the fastest way to get assigned. Please also understand that No gender preference means male or female therapist assigned. And clinician of color means any non-white clinician.
Service delivery preference
*
No preference First available in-person or remote session - (Fastest)
In Person Only - (Face to Face)
Telehealth Only - (Remote Therapy) (Faster)
Please know that we have different providers for different services. Due to the pandemic the in person services are very limited while telehealth options are more flexible and expansive at the moment.
What (No Preference) services are you seeking?
*
Select Service
(No Preference) Couples Therapy
(No Preference) Family Therapy
(No Preference) Group Therapy
(No Preference) Individual Therapy
(No Preference) Licensure Supervision
These sessions could be scheduled for in person or telehealth, whichever is available first.
What Telehealth services are you seeking?
*
Select Service
[Telehealth] Couples Therapy
[Telehealth] Family Therapy
[Telehealth] Group Therapy
[Telehealth] Individual Therapy
[Telehealth] Licensure Supervision
These sessions are only scheduled for remote telehealth sessions.
What in-person services are you seeking?
*
Select Service
[In-Person] Couples Therapy
[In-Person] Family Therapy
[In-Person] Group Therapy
[In-Person] Individual Therapy
[In-Person] Licensure Supervision
These sessions are only scheduled for in-person face to face sessions.
Partners Name
*
First
Last
Partners Cell Number
*
Partners email
*
Has the partner agreed to also participate in therapy?
*
Yes
No
What is the partners motivation level for participating in couples therapy?
Selected Value:
1
Share their rating of possible engagement and motivation for therapy.
1st Choice of No Preference Clinician (All Locations)
*
Select the Therapist you want most.
(Fastest) (No Preference) Any Clinician
(Fastest assignment) Rong Tan (Clinical Intern)
(Fastest assignment) Elizabeth O’Connor (Clinical Intern)
(Fastest assignment) Elana Pijanowski (Clinical Intern)
(Fastest assignment) Patrice Howell (Clinical Intern)
(Fastest assignment) Cindy Jean-Georges (Clinical Intern)
(Short wait) Safiatou Diallo (Clinical Intern)
(No Wait) Christopher Blanco Ramos, MSW
(No Wait) David Pransky, LICSW
(No Wait) Monica Nantege, MSW
(1 week wait est) Catalina Ocampo, LCSW
(1 week wait est) Jessica Furtado, MSW
(1 Week wait est) Maia Roper, LICSW
(2 week wait est) Hannah Rogers (Clinical Intern)
(2 week wait est) Amanda Sepe, LCSW
(2 week wait est) Audrey Casey, LCSW
(2 week wait est) Samantha Leong, MSW
(3 week wait est) Christopher Nemergut
(3 week wait est) Carolyn Gallagher, LCSW
(1 Month wait est) Myveca Saint Vil Pimentel, MFT
(3 week wait est) Maya Lique, MSW
(2 week wait est) Nikki Bansal
(2 Month wait est) Ellie Utset
(2 Month wait est) Elizabeth Smith, MSW
(2 Month wait est) Emily Marini, MSW
(3 Month wait est) Kendra Lisenby, MHC
(3 Month wait est) Nicholas Casali, LCSW
(4 Month wait est) Dariana Quinones-Rexach, LICSW
(4 Month wait est) Tara Hagopian, LCSW
(4 Month wait est) Isoken Osazee, LCSW
(5 Month) Abby Smargon, MSW
2nd Choice of No Preference Clinician (All Locations)
*
Select 2nd option
(Fastest) (No Preference) Any Clinician
(3 day wait) Rong Tan (Clinical Intern)
(3 day wait) Elizabeth O’Connor (Clinical Intern)
(3 day wait) Elana Pijanowski (Clinical Intern)
(3 day wait) Patrice Howell (Clinical Intern)
(3 day wait) Cindy Jean-Georges (Clinical Intern)
(3 day wait) Safiatou Diallo (Clinical Intern)
(No Wait) Christopher Blanco Ramos, MSW
(No Wait) David Pransky, LICSW
(No Wait) Monica Nantege, MSW
(1 week wait est) Catalina Ocampo, LCSW
(1 week wait est) Jessica Furtado, MSW
(1 Week wait est) Maia Roper, LICSW
(2 week wait est) Hannah Rogers (Clinical Intern)
(2 week wait est) Amanda Sepe, LCSW
(2 week wait est) Audrey Casey, LCSW
(2 week wait est) Samantha Leong, MSW
(3 week wait est) Christopher Nemergut
(3 week wait est) Carolyn Gallagher, LCSW
(1 Month wait est) Myveca Saint Vil Pimentel, MFT
(3 week wait est) Maya Lique, MSW
(2 week wait est) Nikki Bansal
(2 Month wait est) Ellie Utset
(2 Month wait est) Elizabeth Smith, MSW
(2 Month wait est) Emily Marini, MSW
(3 Month wait est) Kendra Lisenby, MHC
(3 Month wait est) Nicholas Casali, LCSW
(4 Month wait est) Dariana Quinones-Rexach, LICSW
(4 Month wait est) Tara Hagopian, LCSW
(4 Month wait est) Isoken Osazee, LCSW
(5 Month) Abby Smargon, MSW
1st Choice of Telehealth Clinician (Any) (All Locations)
*
Select the Therapist you want most.
(Fastest) (No Preference) Any Clinician
(Sep 2023 Available) Rong Tan (Clinical Intern)
(Sep 2023 Available) Elizabeth O’Connor (Clinical Intern)
(Sep 2023 Available) Elana Pijanowski (Clinical Intern)
(No Wait) Hannah Rogers (Clinical Intern)
(No Wait) Christopher Blanco Ramos, MSW
(No Wait) David Pransky, LICSW
(No Wait) Monica Nantege, MSW
(1 week wait est) Catalina Ocampo, LCSW
(1 week wait est) Jessica Furtado, MSW
(1 Week wait est) Maia Roper, LICSW
(4 week wait est) Carolyn Gallagher, LCSW
(2 week wait est) Christopher Nemergut
(2 week wait est) Amanda Sepe, LCSW
(2 week wait est) Audrey Casey, LCSW
(2 week wait est) Samantha Leong, MSW
(1 Month wait est) Myveca Saint Vil Pimentel, MFT
(2 week wait est) Abby Smargon, MSW
(3 week wait est) Maya Lique, MSW
(3 week wait est) Emily Marini, MSW
(3 week wait est) Nikki Bansal
(1 Month wait est) Shamiah Tasker-Cheeks, MSW
(2 Month wait est) Partaja Spann, LCSW
(2 Month wait est) Ellie Utset
(2 Month wait est) Elizabeth Smith, MSW
(3 Month wait est) Kendra Lisenby, MHC
(3 Month wait est) Tara Hagopian, LCSW
(3 Month wait est) Nicholas Casali, LCSW
(3 Month wait est) Dariana Quinones-Rexach, LICSW
(4 Month wait est) Isoken Osazee, LCSW
2nd Choice of Telehealth Clinician (Any) (All Locations)
*
Choose a Backup Option
(Fastest) (No Preference) Any Clinician
(Sep 2023 Available) Rong Tan (Clinical Intern)
(Sep 2023 Available) Elizabeth O’Connor (Clinical Intern)
(Sep 2023 Available) Elana Pijanowski (Clinical Intern)
(No Wait) Hannah Rogers (Clinical Intern)
(No Wait) Christopher Blanco Ramos, MSW
(No Wait) David Pransky, LICSW
(No Wait) Monica Nantege, MSW
(1 week wait est) Catalina Ocampo, LCSW
(1 week wait est) Jessica Furtado, MSW
(1 Week wait est) Maia Roper, LICSW
(4 week wait est) Carolyn Gallagher, LCSW
(2 week wait est) Christopher Nemergut
(2 week wait est) Amanda Sepe, LCSW
(2 week wait est) Audrey Casey, LCSW
(2 week wait est) Samantha Leong, MSW
(1 Month wait est) Myveca Saint Vil Pimentel, MFT
(2 week wait est) Abby Smargon, MSW
(3 week wait est) Maya Lique, MSW
(3 week wait est) Emily Marini, MSW
(3 week wait est) Nikki Bansal
(1 Month wait est) Shamiah Tasker-Cheeks, MSW
(2 Month wait est) Partaja Spann, LCSW
(2 Month wait est) Ellie Utset
(2 Month wait est) Elizabeth Smith, MSW
(3 Month wait est) Kendra Lisenby, MHC
(3 Month wait est) Tara Hagopian, LCSW
(3 Month wait est) Nicholas Casali, LCSW
(3 Month wait est) Dariana Quinones-Rexach, LICSW
(4 Month wait est) Isoken Osazee, LCSW
Select a different option than the first one choosen.
1st Choice of Telehealth Clinician (Person of Color) (All Locations)
*
Select the Therapist you want most.
(Fastest) (No Preference) Any Clinician of Color
(Sep 2023 Available) Rong Tan (Clinical Intern)
(No Wait) Christopher Blanco Ramos, MSW
(No Wait) Monica Nantege, MSW
(1 week wait est) Catalina Ocampo, LCSW
(1 week wait est) Jessica Furtado, MSW
(2 week wait est) Samantha Leong, MSW
(1 Month wait est) Myveca Saint Vil Pimentel, MFT
(3 week wait est) Maya Lique, MSW
(3 week wait est) Nikki Bansal
(1 Month wait est) Shamiah Tasker-Cheeks, MSW
(2 Month wait est) Partaja Spann, LCSW
(2 Month wait est) Ellie Utset
(2 Month wait est) Elizabeth Smith, MSW
(3 Month wait est) Kendra Lisenby, MHC
(3 Month wait est) Dariana Quinones-Rexach, LICSW
(4 Month wait est) Isoken Osazee, LCSW
2nd Choice of Telehealth Clinician (Person of Color) (All Locations)
*
Choose a Backup Option
(Fastest) (No Preference) Any Clinician of Color
(Sep 2023 Available) Rong Tan (Clinical Intern)
(No Wait) Christopher Blanco Ramos, MSW
(No Wait) Monica Nantege, MSW
(1 week wait est) Catalina Ocampo, LCSW
(1 week wait est) Jessica Furtado, MSW
(2 week wait est) Samantha Leong, MSW
(1 Month wait est) Myveca Saint Vil Pimentel, MFT
(3 week wait est) Maya Lique, MSW
(3 week wait est) Nikki Bansal
(1 Month wait est) Shamiah Tasker-Cheeks, MSW
(2 Month wait est) Partaja Spann, LCSW
(2 Month wait est) Ellie Utset
(2 Month wait est) Elizabeth Smith, MSW
(3 Month wait est) Kendra Lisenby, MHC
(3 Month wait est) Dariana Quinones-Rexach, LICSW
(4 Month wait est) Isoken Osazee, LCSW
Select a different option than the first selection.
1st Choice of In-Person Clinician (Person of Color) (Dedham)
*
Select the Therapist you want most.
(Fastest) (Clinician of Color) (In-Person) (Dedham)
(Sep 2023 Available) Rong Tan (Clinical Intern)
(No Wait) Monica Nantege, MSW
(1 week wait est) Catalina Ocampo, LCSW
(1 week wait est) Jessica Furtado, MSW
(2 Month wait est) Elizabeth Smith, MSW
(3 Month wait est) Kendra Lisenby, MHC
2nd Choice of In-Person Clinician (Person of Color) (Dedham)
*
Choose a Backup option
(Fastest) (Clinician of Color) (In-Person) (Dedham)
(Sep 2023 Available) Rong Tan (Clinical Intern)
(No Wait) Monica Nantege, MSW
(1 week wait est) Catalina Ocampo, LCSW
(1 week wait est) Jessica Furtado, MSW
(2 Month wait est) Elizabeth Smith, MSW
(3 Month wait est) Kendra Lisenby, MHC
Select a different clinician than the first choice.
1st Choice of In-Person Clinician (Person of Color) (Lincoln)
*
Select the Therapist you want most.
Fastest) (Clinician of Color) (In-Person) (Lincoln)
(No Wait) Christopher Blanco Ramos, MSW
(3 week wait est) Maya Lique, MSW
2nd Choice of In-Person Clinician (Person of Color) (Lincoln)
*
Choose a Backup option
Fastest) (Clinician of Color) (In-Person) (Lincoln)
(No Wait) Christopher Blanco Ramos, MSW
(3 week wait est) Maya Lique, MSW
Select a different clinician from the first choice.
1st Choice of In-Person Clinician (Any)(Dedham)
*
Select the Therapist you want most.
(Fastest) (No Preference) (In-Person) (Dedham)
(Sep 2023 Available) Rong Tan (Clinical Intern)
(Sep 2023 Available) Elizabeth O’Connor (Clinical Intern)
(Sep 2023 Available) Elana Pijanowski (Clinical Intern)
(No Wait) Hannah Rogers (Clinical Intern)
(No Wait) David Pransky, LICSW
(No Wait) Monica Nantege, MSW
(1 week wait est) Catalina Ocampo, LCSW
(1 week wait est) Jessica Furtado, MSW
(4 week wait est) Carolyn Gallagher, LCSW
(2 Month wait est) Elizabeth Smith, MSW
(3 Month wait est) Kendra Lisenby, MHC
(3 Month wait est) Nicholas Casali, LCSW
2nd Choice of In-Person Clinician (Any)(Dedham)
*
Choose a Backup Option
(Fastest) (No Preference) (In-Person) (Dedham)
(Sep 2023 Available) Rong Tan (Clinical Intern)
(Sep 2023 Available) Elizabeth O’Connor (Clinical Intern)
(Sep 2023 Available) Elana Pijanowski (Clinical Intern)
(No Wait) Hannah Rogers (Clinical Intern)
(No Wait) David Pransky, LICSW
(No Wait) Monica Nantege, MSW
(1 week wait est) Catalina Ocampo, LCSW
(1 week wait est) Jessica Furtado, MSW
(4 week wait est) Carolyn Gallagher, LCSW
(2 Month wait est) Elizabeth Smith, MSW
(3 Month wait est) Kendra Lisenby, MHC
(3 Month wait est) Nicholas Casali, LCSW
Select a different option than the first one choosen.
1st Choice of In-Person Clinician (Any)(Lincoln)
*
Select the Therapist you want most.
(Fastest) (Clinician of Color) (In-Person) (Lincoln)
(No Wait) Christopher Blanco Ramos, MSW
(3 week wait est) Maya Lique, MSW
2nd Choice of In-Person Clinician (Any)(Lincoln)
*
Choose a backup option
(Fastest) (Clinician of Color) (In-Person) (Lincoln)
(No Wait) Christopher Blanco Ramos, MSW
(3 week wait est) Maya Lique, MSW
1st Choice of Telehealth Clinician (Any Male) (All Locations)
*
Select the Therapist you want most.
Male Clinician (No racial preference)
(No Wait) Christopher Blanco Ramos, MSW
(No Wait) David Pransky, LICSW
(2 week wait est) Christopher Nemergut
(3 Month wait est) Nicholas Casali, LCSW
2nd Choice of Telehealth Clinician (Any Male) (All Locations)
*
Select the Therapist you want most.
Male Clinician (No racial preference) (remote)
(No Wait) Christopher Blanco Ramos, MSW
(No Wait) David Pransky, LICSW
(2 week wait est) Christopher Nemergut
(3 Month wait est) Nicholas Casali, LCSW
1st Choice of In-Person Clinician (Any Male) (Dedham)
*
Select the Therapist you want most.
Male Clinician (No racial preference) (Dedham)
(No Wait) David Pransky, LICSW
(2 week wait est) Christopher Nemergut
2nd Choice of In-Person Clinician (Any Male) (Dedham)
*
Choose a Backup Option
Male Clinician (No racial preference) (Dedham)
(No Wait) David Pransky, LICSW
(2 week wait est) Christopher Nemergut
Select a different option than the first one chosen.
1st Choice of In-Person Clinician (Any Male) (Lincoln)
*
Select the Therapist you want most.
Male Clinician (No racial preference) (Dedham)
(No Wait) Christopher Blanco Ramos, MSW
2nd Choice of In-Person Clinician (Any Male) (Lincoln)
*
Choose a Backup Option
Male Clinician (No racial preference) (Dedham)
(No Wait) Christopher Blanco Ramos, MSW
1st Choice of Telehealth Clinician (Any Female) (All Locations)
*
Select the Therapist you want most.
(Fastest) (Female Clinician) (Remote)
(Sep 2023 Available) Rong Tan (Clinical Intern)
(Sep 2023 Available) Elizabeth O’Connor (Clinical Intern)
(Sep 2023 Available) Elana Pijanowski (Clinical Intern)
(No Wait) Hannah Rogers (Clinical Intern)
(No Wait) Monica Nantege, MSW
(1 week wait est) Catalina Ocampo, LCSW
(1 week wait est) Jessica Furtado, MSW
(1 Week wait est) Maia Roper, LICSW
(4 week wait est) Carolyn Gallagher, LCSW
(2 week wait est) Amanda Sepe, LCSW
(2 week wait est) Audrey Casey, LCSW
(2 week wait est) Samantha Leong, MSW
(1 Month wait est) Myveca Saint Vil Pimentel, MFT
(2 week wait est) Abby Smargon, MSW
(3 week wait est) Maya Lique, MSW
(3 week wait est) Emily Marini, MSW
(3 week wait est) Nikki Bansal
(1 Month wait est) Shamiah Tasker-Cheeks, MSW
(2 Month wait est) Partaja Spann, LCSW
(2 Month wait est) Ellie Utset
(2 Month wait est) Elizabeth Smith, MSW
(3 Month wait est) Kendra Lisenby, MHC
(3 Month wait est) Tara Hagopian, LCSW
(3 Month wait est) Dariana Quinones-Rexach, LICSW
(4 Month wait est) Isoken Osazee, LCSW
2nd Choice of Telehealth Clinician (Any Female) (All Locations)
*
Select the Therapist you want most.
(Fastest) (Female Clinician) (Remote)
(Sep 2023 Available) Rong Tan (Clinical Intern)
(Sep 2023 Available) Elizabeth O’Connor (Clinical Intern)
(Sep 2023 Available) Elana Pijanowski (Clinical Intern)
(No Wait) Hannah Rogers (Clinical Intern)
(No Wait) Monica Nantege, MSW
(1 week wait est) Catalina Ocampo, LCSW
(1 week wait est) Jessica Furtado, MSW
(1 Week wait est) Maia Roper, LICSW
(4 week wait est) Carolyn Gallagher, LCSW
(2 week wait est) Amanda Sepe, LCSW
(2 week wait est) Audrey Casey, LCSW
(2 week wait est) Samantha Leong, MSW
(1 Month wait est) Myveca Saint Vil Pimentel, MFT
(2 week wait est) Abby Smargon, MSW
(3 week wait est) Maya Lique, MSW
(3 week wait est) Emily Marini, MSW
(3 week wait est) Nikki Bansal
(1 Month wait est) Shamiah Tasker-Cheeks, MSW
(2 Month wait est) Partaja Spann, LCSW
(2 Month wait est) Ellie Utset
(2 Month wait est) Elizabeth Smith, MSW
(3 Month wait est) Kendra Lisenby, MHC
(3 Month wait est) Tara Hagopian, LCSW
(3 Month wait est) Dariana Quinones-Rexach, LICSW
(4 Month wait est) Isoken Osazee, LCSW
1st Choice of In-Person Clinician (Any Female) (Lincoln)
*
Select the Therapist you want most.
Any Female Clinician (Lincoln)
(1 Week wait est) Maia Roper, LICSW
(2 week wait est) Amanda Sepe, LCSW
(2 week wait est) Audrey Casey, LCSW
(3 week wait est) Maya Lique, MSW
2nd Choice of In-Person Clinician (Any Female) (Lincoln)
*
Choose a Backup Option
Any Female Clinician (Lincoln)
(1 Week wait est) Maia Roper, LICSW
(2 week wait est) Amanda Sepe, LCSW
(2 week wait est) Audrey Casey, LCSW
(3 week wait est) Maya Lique, MSW
Select a different option than the first one chosen.
1st Choice of In-Person Clinician (Any Female) (Dedham)
*
Select the Therapist you want most.
Any Female Clinician (Dedham)
(Sep 2023 Available) Rong Tan (Clinical Intern)
(Sep 2023 Available) Elizabeth O’Connor (Clinical Intern)
(Sep 2023 Available) Elana Pijanowski (Clinical Intern)
(No Wait) Hannah Rogers (Clinical Intern)
(No Wait) Monica Nantege, MSW
(1 week wait est) Catalina Ocampo, LCSW
(1 week wait est) Jessica Furtado, MSW
(4 week wait est) Carolyn Gallagher, LCSW
(2 Month wait est) Elizabeth Smith, MSW
(3 Month wait est) Kendra Lisenby, MHC
2nd Choice of In-Person Clinician (Any Female) (Dedham)
*
Choose a Backup Option
Any Female Clinician (Dedham)
(Sep 2023 Available) Rong Tan (Clinical Intern)
(Sep 2023 Available) Elizabeth O’Connor (Clinical Intern)
(Sep 2023 Available) Elana Pijanowski (Clinical Intern)
(No Wait) Hannah Rogers (Clinical Intern)
(No Wait) Monica Nantege, MSW
(1 week wait est) Catalina Ocampo, LCSW
(1 week wait est) Jessica Furtado, MSW
(4 week wait est) Carolyn Gallagher, LCSW
(2 Month wait est) Elizabeth Smith, MSW
(3 Month wait est) Kendra Lisenby, MHC
Select a different option than the first one chosen.
1st Choice of Telehealth Clinician (Black female) (All Locations)
*
Select the Therapist you want most.
Black Female Clinician (remote) (Fastest)
(No Wait) Monica Nantege, MSW
(1 Month wait est) Myveca Saint Vil Pimentel, MFT
(1 Month wait est) Shamiah Tasker-Cheeks, MSW
(2 Month wait est) Partaja Spann, LCSW
(2 Month wait est) Elizabeth Smith, MSW
(3 Month wait est) Kendra Lisenby, MHC
(4 Month wait est) Isoken Osazee, LCSW
2nd Choice of Telehealth Clinician (Black female) (All Locations)
*
Choose a Backup Option
Black Female Clinician (remote) (Fastest)
(No Wait) Monica Nantege, MSW
(1 Month wait est) Myveca Saint Vil Pimentel, MFT
(1 Month wait est) Shamiah Tasker-Cheeks, MSW
(2 Month wait est) Partaja Spann, LCSW
(2 Month wait est) Elizabeth Smith, MSW
(3 Month wait est) Kendra Lisenby, MHC
(4 Month wait est) Isoken Osazee, LCSW
Select a different option than the first one.
1st Choice of In-Person Clinician (Black female) (Lincoln)
*
Select the Therapist you want most.
(No Clinicians fit this criteria at the moment.)
2nd Choice of In-Person Clinician (Black female) (Lincoln)
*
Choose a Backup option
(No Clinicians fit this criteria at the moment.)
Select a different option than the first one chosen.
1st Choice of In-Person Clinician (Black female) (Dedham)
*
Select the Therapist you want most.
Black Female Clinician (remote) (Fastest)
(No Wait) Monica Nantege, MSW
(2 Month wait est) Elizabeth Smith, MSW
(3 Month wait est) Kendra Lisenby, MHC
2nd Choice of In-Person Clinician (Black female) (Dedham)
*
Choose a Backup option
Black Female Clinician (remote) (Fastest)
(No Wait) Monica Nantege, MSW
(2 Month wait est) Elizabeth Smith, MSW
(3 Month wait est) Kendra Lisenby, MHC
Select a different option than the first one chosen.
1st Choice of Telehealth Clinician (Black) (All Locations)
*
Select the Therapist you want most.
Black Clinician (M/F) (remote) (fastest)
(No Wait) Monica Nantege, MSW
(1 Month wait est) Myveca Saint Vil Pimentel, MFT
(1 Month wait est) Shamiah Tasker-Cheeks, MSW
(2 Month wait est) Partaja Spann, LCSW
(2 Month wait est) Elizabeth Smith, MSW
(3 Month wait est) Kendra Lisenby, MHC
(4 Month wait est) Isoken Osazee, LCSW
2nd Choice of Telehealth Clinician (Black) (All Locations)
*
Choose a Backup Option
Black Clinician (M/F) (remote) (fastest)
(No Wait) Monica Nantege, MSW
(1 Month wait est) Myveca Saint Vil Pimentel, MFT
(1 Month wait est) Shamiah Tasker-Cheeks, MSW
(2 Month wait est) Partaja Spann, LCSW
(2 Month wait est) Elizabeth Smith, MSW
(3 Month wait est) Kendra Lisenby, MHC
(4 Month wait est) Isoken Osazee, LCSW
Select a different option than the first.
1st Choice of In-Person Clinician (Black) (Dedham)
*
Select the Therapist you want most.
Black Clinician (M/F) (Dedham) (fastest)
(No Wait) Monica Nantege, MSW
(2 Month wait est) Elizabeth Smith, MSW
(3 Month wait est) Kendra Lisenby, MHC
2nd Choice of In-Person Clinician (Black) (Dedham)
*
Choose a Backup Option
Black Clinician (M/F) (Dedham) (fastest)
(No Wait) Monica Nantege, MSW
(2 Month wait est) Elizabeth Smith, MSW
(3 Month wait est) Kendra Lisenby, MHC
Select a different option than the first one chosen.
1st Choice of In-Person Clinician (Black) (Lincoln)
*
Select the Therapist you want most.
(No Clinicians fit this criteria at the moment.)
2nd Choice of In-Person Clinician (Black) (Lincoln)
*
Choose a Backup Option
(No Clinicians fit this criteria at the moment.)
Select a different option than the first one chosen.
1st Choice of Telehealth Clinician (Black Male) (All Locations)
*
Select the Therapist you want most.
(No Clinicians fit this criteria at the moment.)
2nd Choice of Telehealth Clinician (Black Male) (All Locations)
*
Choose a Backup Option
(No Clinicians fit this criteria at the moment.)
Select a different option than the first one chosen.
1st Choice of In-Person Clinician (Black Male) (Dedham)
*
Select the Therapist you want most.
(No Clinicians fit this criteria at the moment.)
2nd Choice of In-Person Clinician (Black Male) (Dedham)
*
Choose a Backup Option
(No Clinicians fit this criteria at the moment.)
Select a different option than the first one chosen.
1st Choice of In-Person Clinician (Black Male) (Lincoln)
*
Select the Therapist you want most.
(No Clinicians fit this criteria at the moment.)
2nd Choice of In-Person Clinician (Black Male) (Lincoln)
*
Select the Therapist you want most.
(No Clinicians fit this criteria at the moment.)
1st Choice of Telehealth Clinician (LatinX) (All Locations)
*
Select the Therapist you want most.
LatinX Clinician (M/F) (remote) (Fastest)
(No Wait) Christopher Blanco Ramos, MSW
(1 week wait est) Catalina Ocampo, LCSW
(1 week wait est) Jessica Furtado, MSW
(2 week wait est) Samantha Leong, MSW
(2 Month wait est) Ellie Utset
(3 Month wait est) Dariana Quinones-Rexach, LICSW
2nd Choice of Telehealth Clinician (LatinX) (All Locations)
*
Choose a Backup Option
LatinX Clinician (M/F) (remote) (Fastest)
(No Wait) Christopher Blanco Ramos, MSW
(1 week wait est) Catalina Ocampo, LCSW
(1 week wait est) Jessica Furtado, MSW
(2 week wait est) Samantha Leong, MSW
(2 Month wait est) Ellie Utset
(3 Month wait est) Dariana Quinones-Rexach, LICSW
Select a different option than the first.
1st Choice of In-Person Clinician (LatinX) (Dedham)
*
Select the Therapist you want most.
(1 week wait est) Jessica Furtado, MSW
(1 week wait est) Catalina Ocampo, LCSW
2nd Choice of In-Person Clinician (LatinX) (Dedham)
*
Choose a Backup Option
(1 week wait est) Jessica Furtado, MSW
(1 week wait est) Catalina Ocampo, LCSW
Select a different option than the first one chosen.
1st Choice of In-Person Clinician (LatinX) (Lincoln)
*
Select the Therapist you want most.
(No Wait) Christopher Blanco Ramos, MSW
2nd Choice of In-Person Clinician (LatinX) (Lincoln)
*
Choose a Backup Option
(No Wait) Christopher Blanco Ramos, MSW
Select a different option than the first one chosen.
1st Choice of Telehealth Clinician (LatinX Female) (All Locations)
*
Select the Therapist you want most.
LatinX Female Clinician (remote) (Fastest)
(1 week wait est) Catalina Ocampo, LCSW
(1 week wait est) Jessica Furtado, MSW
(2 week wait est) Samantha Leong, MSW
(2 Month wait est) Ellie Utset
(3 Month wait est) Dariana Quinones-Rexach, LICSW
2nd Choice of Telehealth Clinician (LatinX Female) (All Locations)
*
Choose a Backup Option
LatinX Female Clinician (remote) (Fastest)
(1 week wait est) Jessica Furtado, MSW
(1 week wait est) Catalina Ocampo, LCSW
(2 week wait est) Samantha Leong, MSW
(2 Month wait est) Ellie Utset
(3 Month wait est) Dariana Quinones-Rexach, LICSW
Select a different option than the first one chosen.
1st Choice of In-Person Clinician (LatinX Female) (Dedham)
*
Select the Therapist you want most.
(1 week wait est) Jessica Furtado, MSW
(1 week wait est) Catalina Ocampo, LCSW
2nd Choice of In-Person Clinician (LatinX Female) (Dedham)
*
Choose a Backup Option
(1 week wait est) Jessica Furtado, MSW
(1 week wait est) Catalina Ocampo, LCSW
Select a different option than the first one chosen.
1st Choice of In-Person Clinician (LatinX Female) (Lincoln)
*
Select the Therapist you want most.
(No Clinicians fit this criteria at the moment.)
2nd Choice of In-Person Clinician (LatinX Female) (Lincoln)
*
Choose a Backup Option
(No Clinicians fit this criteria at the moment.)
Select a different option than the first one chosen.
1st Choice of Telehealth Clinician (LatinX Male) (All Locations)
*
Select the Therapist you want most.
(No Wait) Christopher Blanco Ramos, MSW
2nd Choice of Telehealth Clinician (LatinX Male) (All Locations)
*
(No Wait) Christopher Blanco Ramos, MSW
1st Choice of In-Person Clinician (LatinX Male) (Dedham)
*
Select the Therapist you want most.
(No Clinicians fit this criteria at the moment.)
2nd Choice of In-Person Clinician (LatinX Male) (Dedham)
*
Select the Therapist you want most.
(No Clinicians fit this criteria at the moment.)
1st Choice of In-Person Clinician (LatinX Male) (Lincoln)
*
Select the Therapist you want most.
(No Wait) Christopher Blanco Ramos, MSW
2nd Choice of In-Person Clinician (LatinX Male) (Lincoln)
*
Select the Therapist you want most.
(No Wait) Christopher Blanco Ramos, MSW
1st Choice of In-Person Clinician (Any) (Lincoln)
*
Select the Therapist you want most.
(No Wait) Christopher Blanco Ramos, MSW
2nd Choice of In-Person Clinician (Any) (Lincoln)
*
Choose a Backup Option
(No Wait) Christopher Blanco Ramos, MSW
Select a different option than the first.
1st Choice of In-Person Clinician (Asian Female Clinician) (Lincoln)
*
Select the Therapist you want most.
(2 week) Maya Lique, MSW
2nd Choice of In-Person Clinician (Asian Female Clinician) (Lincoln)
*
Select the Therapist you want most.
(2 week) Maya Lique, MSW
1st Choice of Telehealth Clinician (Any Asian Clinician) (Remote)
*
Select the Therapist you want most.
(2 week) Maya Lique, MSW
2nd Choice of Telehealth Clinician (Any Asian Clinician) (Remote)
*
Select the Therapist you want most.
(2 week) Maya Lique, MSW
1st Choice of (no preference) White Clinician
*
Select the Therapist you want most.
(Fastest) (Remote) First available white clinician
(Sep 2023 Available) Elizabeth O’Connor (Clinical Intern)
(Sep 2023 Available) Elana Pijanowski (Clinical Intern)
(No Wait) Hannah Rogers (Clinical Intern)
(1 Week) David Pransky, LICSW
(1 Week wait est) Maia Roper, LICSW
(4 week wait est) Carolyn Gallagher, LCSW
(2 week wait est) Christopher Nemergut
(2 week wait est) Amanda Sepe, LCSW
(2 week wait est) Audrey Casey, LCSW
(2 week wait est) Abby Smargon, MSW
(3 week wait est) Emily Marini, MSW
(3 Month wait est) Tara Hagopian, LCSW
(3 Month wait est) Nicholas Casali, LCSW
2nd Choice of (no preference) White Clinician
*
Select the Therapist you want most.
(Fastest) (Remote) First available white clinician
(Sep 2023 Available) Elizabeth O’Connor (Clinical Intern)
(Sep 2023 Available) Elana Pijanowski (Clinical Intern)
(No Wait) Hannah Rogers (Clinical Intern)
(1 Week) David Pransky, LICSW
(1 Week wait est) Maia Roper, LICSW
(4 week wait est) Carolyn Gallagher, LCSW
(2 week wait est) Christopher Nemergut
(2 week wait est) Amanda Sepe, LCSW
(2 week wait est) Audrey Casey, LCSW
(2 week wait est) Abby Smargon, MSW
(3 week wait est) Emily Marini, MSW
(3 Month wait est) Tara Hagopian, LCSW
(3 Month wait est) Nicholas Casali, LCSW
1st Choice of (no preference) White Clinician (Remote)
*
Select the Therapist you want most.
(Fastest) (Remote) First available white clinician
(Sep 2023 Available) Elizabeth O’Connor (Clinical Intern)
(Sep 2023 Available) Elana Pijanowski (Clinical Intern)
(No Wait) Hannah Rogers (Clinical Intern)
(1 Week) David Pransky, LICSW
(1 Week wait est) Maia Roper, LICSW
(4 week wait est) Carolyn Gallagher, LCSW
(2 week wait est) Christopher Nemergut
(2 week wait est) Amanda Sepe, LCSW
(2 week wait est) Audrey Casey, LCSW
(2 week wait est) Abby Smargon, MSW
(3 week wait est) Emily Marini, MSW
(3 Month wait est) Tara Hagopian, LCSW
(3 Month wait est) Nicholas Casali, LCSW
2nd Choice of (no preference) White Clinician (Remote)
*
Select the Therapist you want most.
(Fastest) (Remote) First available white clinician
(Sep 2023 Available) Elizabeth O’Connor (Clinical Intern)
(Sep 2023 Available) Elana Pijanowski (Clinical Intern)
(No Wait) Hannah Rogers (Clinical Intern)
(1 Week) David Pransky, LICSW
(1 Week wait est) Maia Roper, LICSW
(4 week wait est) Carolyn Gallagher, LCSW
(2 week wait est) Christopher Nemergut
(2 week wait est) Amanda Sepe, LCSW
(2 week wait est) Audrey Casey, LCSW
(2 week wait est) Abby Smargon, MSW
(3 week wait est) Emily Marini, MSW
(3 Month wait est) Tara Hagopian, LCSW
(3 Month wait est) Nicholas Casali, LCSW
1st Choice of White Female Clinician (Remote)
*
Select the Therapist you want most.
(Fastest) (Remote) First available white clinician
(Sep 2023 Available) Elizabeth O’Connor (Clinical Intern)
(Sep 2023 Available) Elana Pijanowski (Clinical Intern)
(No Wait) Hannah Rogers (Clinical Intern)
(1 Week wait est) Maia Roper, LICSW
(4 week wait est) Carolyn Gallagher, LCSW
(2 week wait est) Amanda Sepe, LCSW
(2 week wait est) Audrey Casey, LCSW
(2 week wait est) Abby Smargon, MSW
(3 week wait est) Emily Marini, MSW
(3 Month wait est) Tara Hagopian, LCSW
2nd Choice of White Female Clinician (Remote)
*
Select the Therapist you want most.
(Fastest) (Remote) First available white clinician
(Sep 2023 Available) Elizabeth O’Connor (Clinical Intern)
(Sep 2023 Available) Elana Pijanowski (Clinical Intern)
(No Wait) Hannah Rogers (Clinical Intern)
(1 Week wait est) Maia Roper, LICSW
(4 week wait est) Carolyn Gallagher, LCSW
(2 week wait est) Amanda Sepe, LCSW
(2 week wait est) Audrey Casey, LCSW
(2 week wait est) Abby Smargon, MSW
(3 week wait est) Emily Marini, MSW
(3 Month wait est) Tara Hagopian, LCSW
1st Choice of White Female Clinician (Dedham)
*
Select the Therapist you want most.
(Fastest) (Remote) First available white clinician
(Sep 2023 Available) Elizabeth O’Connor (Clinical Intern)
(Sep 2023 Available) Elana Pijanowski (Clinical Intern)
(No Wait) Hannah Rogers (Clinical Intern)
(4 week wait est) Carolyn Gallagher, LCSW
(2 week wait est) Audrey Casey, LCSW
(2 week wait est) Abby Smargon, MSW
(3 week wait est) Emily Marini, MSW
(3 Month wait est) Tara Hagopian, LCSW
2nd Choice of White Female Clinician (Dedham)
*
Select the Therapist you want most.
(Fastest) (Remote) First available white clinician
(Sep 2023 Available) Elizabeth O’Connor (Clinical Intern)
(Sep 2023 Available) Elana Pijanowski (Clinical Intern)
(No Wait) Hannah Rogers (Clinical Intern)
(4 week wait est) Carolyn Gallagher, LCSW
(2 week wait est) Audrey Casey, LCSW
(2 week wait est) Abby Smargon, MSW
(3 week wait est) Emily Marini, MSW
(3 Month wait est) Tara Hagopian, LCSW
1st Choice of White Female Clinician (Lincoln)
*
Select the Therapist you want most.
(Fastest) (Remote) First available white clinician
(1 Week wait est) Maia Roper, LICSW
(2 week wait est) Amanda Sepe, LCSW
2nd Choice of White Female Clinician (Lincoln)
*
Select the Therapist you want most.
(Fastest) (Remote) First available white clinician
(1 Week wait est) Maia Roper, LICSW
(2 week wait est) Amanda Sepe, LCSW
1st Choice of In-Person White Male Clinician (Dedham)
*
Select the Therapist you want most.
(Fastest) (Remote) First available white clinician
(1 Week) David Pransky, LICSW
(3 Month wait est) Nicholas Casali, LCSW
2nd Choice of In-Person White Male Clinician (Dedham)
*
Select the Therapist you want most.
(Fastest) (Remote) First available white clinician
(1 Week) David Pransky, LICSW
(3 Month wait est) Nicholas Casali, LCSW
1st Choice of In-Person White Male Clinician (Lincoln)
*
Select the Therapist you want most.
No clinicians meet this criteria
2nd Choice of In-Person White Male Clinician (Lincoln)
*
Select the Therapist you want most.
No clinicians meet this criteria
Do you know of any friends or Relatives who are currently receiving services at GENNEW?
*
Select Choice
No
Yes
What is the persons name?
*
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.
*
What provider made the formal diagnosis?
*
What was the diagnosis?
*
How recent was the last suicide attempt?
*
When was the last session and what was the therapists name?
*
Reason for transition?
*
Can you share why you are no longer with the previous therapist?
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 Family Member
My Client
Please explain your relation to the potential client.
Referrer Name
*
First
Last
Referrer Email
*
Referrer Phone
*
Do you have a referral / case number?
Your insurance provider may have given you a Case / Referral #
What issue caused you to seek therapy?
*
Please be very detailed so that we can match you to the appropriate therapist. The more we know the better we can match you with an appropriate therapist. Please don't just put depression, please share what you think may be causing the depression or any issues going on in your life.
Client Availability for sessions? Dates and Times
*
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.
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