Request an Appointment

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? *

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 *

Insurance # / Member ID / Masshealth # *

EAP Services requested 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.

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's the second Insurance? *

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? *

To better assign you to a clinician.

Clinician Preference *

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 *

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? *

These sessions could be scheduled for in person or telehealth, whichever is available first.

What Telehealth services are you seeking? *

These sessions are only scheduled for remote telehealth sessions.

What in-person services are you seeking? *

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) *

2nd Choice of No Preference Clinician (All Locations) *

Select a different option than the first one choosen.

1st Choice of Telehealth Clinician (Any) (All Locations) *

2nd Choice of Telehealth Clinician (Any) (All Locations) *

Select a different option than the first one choosen.

1st Choice of Telehealth Clinician (Person of Color) (All Locations) *

2nd Choice of Telehealth Clinician (Person of Color) (All Locations) *

Select a different option than the first selection.

1st Choice of In-Person Clinician (Person of Color) (Dedham) *

2nd Choice of In-Person Clinician (Person of Color) (Dedham) *

Select a different clinician than the first choice.

1st Choice of In-Person Clinician (Person of Color) (Lincoln) *

2nd Choice of In-Person Clinician (Person of Color) (Lincoln) *

Select a different clinician from the first choice.

1st Choice of In-Person Clinician (Any)(Dedham) *

2nd Choice of In-Person Clinician (Any)(Dedham) *

Select a different option than the first one choosen.

1st Choice of Telehealth Clinician (Any Male) (All Locations) *

2nd Choice of Telehealth Clinician (Any Male) (All Locations) *

1st Choice of In-Person Clinician (Any Male) (Dedham) *

2nd Choice of In-Person Clinician (Any Male) (Dedham) *

Select a different option than the first one chosen.

1st Choice of In-Person Clinician (Any Male) (Lincoln) *

2nd Choice of In-Person Clinician (Any Male) (Lincoln) *

1st Choice of Telehealth Clinician (Any Female) (All Locations) *

2nd Choice of Telehealth Clinician (Any Female) (All Locations) *

1st Choice of In-Person Clinician (Any Female) (Lincoln) *

2nd Choice of In-Person Clinician (Any Female) (Lincoln) *

Select a different option than the first one chosen.

1st Choice of In-Person Clinician (Any Female) (Dedham) *

2nd Choice of In-Person Clinician (Any Female) (Dedham) *

Select a different option than the first one chosen.

1st Choice of Telehealth Clinician (Black female) (All Locations) *

2nd Choice of Telehealth Clinician (Black female) (All Locations) *

Select a different option than the first one.

1st Choice of In-Person Clinician (Black female) (Lincoln) *

2nd Choice of In-Person Clinician (Black female) (Lincoln) *

Select a different option than the first one chosen.

1st Choice of In-Person Clinician (Black female) (Dedham) *

2nd Choice of In-Person Clinician (Black female) (Dedham) *

Select a different option than the first one chosen.

1st Choice of Telehealth Clinician (Black) (All Locations) *

2nd Choice of Telehealth Clinician (Black) (All Locations) *

Select a different option than the first.

1st Choice of In-Person Clinician (Black) (Dedham) *

2nd Choice of In-Person Clinician (Black) (Dedham) *

Select a different option than the first one chosen.

1st Choice of In-Person Clinician (Black) (Lincoln) *

2nd Choice of In-Person Clinician (Black) (Lincoln) *

Select a different option than the first one chosen.

1st Choice of Telehealth Clinician (Black Male) (All Locations) *

2nd Choice of Telehealth Clinician (Black Male) (All Locations) *

Select a different option than the first one chosen.

1st Choice of In-Person Clinician (Black Male) (Dedham) *

2nd Choice of In-Person Clinician (Black Male) (Dedham) *

Select a different option than the first one chosen.

1st Choice of In-Person Clinician (Black Male) (Lincoln) *

2nd Choice of In-Person Clinician (Black Male) (Lincoln) *

1st Choice of Telehealth Clinician (LatinX) (All Locations) *

2nd Choice of Telehealth Clinician (LatinX) (All Locations) *

Select a different option than the first.

1st Choice of In-Person Clinician (LatinX) (Dedham) *

2nd Choice of In-Person Clinician (LatinX) (Dedham) *

Select a different option than the first one chosen.

1st Choice of In-Person Clinician (LatinX) (Lincoln) *

2nd Choice of In-Person Clinician (LatinX) (Lincoln) *

Select a different option than the first one chosen.

1st Choice of Telehealth Clinician (LatinX Female) (All Locations) *

2nd Choice of Telehealth Clinician (LatinX Female) (All Locations) *

Select a different option than the first one chosen.

1st Choice of In-Person Clinician (LatinX Female) (Dedham) *

2nd Choice of In-Person Clinician (LatinX Female) (Dedham) *

Select a different option than the first one chosen.

1st Choice of In-Person Clinician (LatinX Female) (Lincoln) *

2nd Choice of In-Person Clinician (LatinX Female) (Lincoln) *

Select a different option than the first one chosen.

1st Choice of Telehealth Clinician (LatinX Male) (All Locations) *

2nd Choice of Telehealth Clinician (LatinX Male) (All Locations) *

1st Choice of In-Person Clinician (LatinX Male) (Dedham) *

2nd Choice of In-Person Clinician (LatinX Male) (Dedham) *

1st Choice of In-Person Clinician (LatinX Male) (Lincoln) *

2nd Choice of In-Person Clinician (LatinX Male) (Lincoln) *

1st Choice of In-Person Clinician (Any) (Lincoln) *

2nd Choice of In-Person Clinician (Any) (Lincoln) *

Select a different option than the first.

Do you know of any friends or Relatives who are currently receiving services at GENNEW? *

What is the persons name? *

Please select all of the following which pertain to the client.

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 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.

Your well-being is in good hands

Request an Appointment