Psychiatric Appointment Request

Name *

First Name

Last Name

Phone* (if ok to leave message)

(###)

###

####

I would like to use SMS text for appointment reminders and the option of using texting as means of general communication (*see privacy policy)

If you wish to stop receiving text messages from us, at any point, reply STOP to any text message sent from us

Yes

No

Insurance Information *

Please select from the in-network plans below. We provide claims forms upon request for out-of-network patients to submit to their insurance company after payment

Anthem or Blue Cross Blue Sheild

Aetna

Behavioral Health Care Plans

Community Helath Options

Harvard Pilgrim

Humana BH

Humana Military

Martin's Point

Medicare

Multiplan

United / Optum

Out-of-network / self pay (Eval $350)

Have you ever been admitted to a higher level of care *

No

Yes - Residential Treatment

Yes - Inpatient Psychiatric Treatment

Yes - Partial Hospitalization Program

Yes - Intensive Outpatient Program

Are you seeking evaluation for legal matters? *

Yes

No