Note: Items mark with an asterisk (*) are required.

* Service (Select One):
Psychotherapy - AdultMedication Consultation - AdultPsychotherapy - Child

* Today's Date:

Referred By:

Patient Information:

* Patient Name:

Parents (if applicable):

* Address 1:

Address 2:

* City:

* State:

* 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:

* Name:

* Insurance Company:

* Policy Number:

* DOB:

* 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

If so, where and when?

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):

Contacting You:

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