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

* Service (Select One):
 Psychotherapy - Adult Psychiatry - Adult Psychotherapy - 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):

* SSN:

* Email Address:

Preferred Method(s) of Contact:

 Home Phone Work Phone Cell Phone Email

Enter Phone Number or Email Address:

Best Day to Call:
 Sunday Monday Tuesday Wednesday Thursday Friday Saturday

Best Time to Call:

Insurance Policy Holder Information:

* Name:

* Insurance Company:

* Policy Number:

* DOB:

* SSN:

* Therapy Requested:  Individual Family Couple

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? Yes No 

If so, with whom and when?

Have you ever been treated by a psychiatrist or a nurse practitioner? Yes No 

If so, where and when?

Have you ever been hospitalized for psychiatric reasons? Yes No 

If so, where and when?

Are you on any psychiatric medications? Yes No 

If so, please list:

Do you have any domestic violence issues? Yes No 

Do you (or your partner) have any substance use/abuse issues? Yes No 

Do you (or your partner) have any legal issues? Yes No 

If yes, to any of the above, please explain:

Do you (or your partner) having any custody issues? Yes No 

If yes, please explain:

If yes, is there any outside agency of involvement? Yes No 

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? Yes No 

...on your voicemail at work? Yes No 

...on your voicemail on your cellphone? Yes No