Note: Items mark with an asterisk (*) are required.
* Service (Select One): Psychotherapy - AdultMedication Consultation - AdultPsychotherapy - Child
* Today's Date:
* Patient Name:
Parents (if applicable):
* Address 1:
* ZIP Code:
* DOB (mm/dd/yyyy):
* Email Address:
Preferred Method(s) of Contact:
Home PhoneWork PhoneCell PhoneEmail
Enter Phone Number or Email Address:
Best Day to Call: SundayMondayTuesdayWednesdayThursdayFridaySaturday
Best Time to Call:
Insurance Policy Holder Information:
* Insurance Company:
* Policy Number:
* Therapy Requested: IndividualFamilyCouple
Description of current problem(s):
Preferred Day/Time for appointment:
The following questions may not apply to you, but please answer them to the best of your ability:
Have you ever attended therapy before? YesNo
If so, with whom and when?
Have you ever been treated by a psychiatrist or a nurse practitioner? YesNo
If so, where and when?
Have you ever been hospitalized for psychiatric reasons? YesNo
Are you on any psychiatric medications? YesNo
If so, please list:
Do you have any domestic violence issues? YesNo
Do you (or your partner) have any substance use/abuse issues? YesNo
Do you (or your partner) have any legal issues? YesNo
If yes, to any of the above, please explain:
Do you (or your partner) having any custody issues? YesNo
If yes, please explain:
If yes, is there any outside agency of involvement? YesNo
If yes, what agency (e.g., DSS, Mass Rehab, Family Services):
May the therapist leave messages for you regarding Atlantic Counseling...
...on your voicemail at home? YesNo
...on your voicemail at work? YesNo
...on your voicemail on your cellphone? YesNo
Please contact the office if you have not received a response within 24 hours.