Referral Intake Forms

Personalized Care | Locally Owned | Walk-Ins Available

Personalized Care
Locally Owned
Walk-Ins Available

Mental Health Clinic Intake Form

If you are interested in becoming a new patient please complete our intake form.

Get in Touch With Us

Name:

Phone:

Address

Social Security #:

Date of Birth:

Gender

Primary Insurance & Insurance ID#

Secondary Insurance & Insurance ID#

Site to be Seen

Reason for Being Seen

Free Text

If for Suboxone, please answer the following questions:

Are you currently taking any illicit substances?

If yes, name of substance:

How long have you been substance free?

Years:

Months:

Days:

Are you currently on Suboxone/Subtex?

if yes, how many milligrams and dosage:

Are you currently seeing a therapist/counselor?

If yes, Name and Location:

(Please describe setting, length)

Psychiatric Diagnosis:

Current Medications:

Do you have a current psychatrist?

If so, who? And why do you need a new prescriber?

Referred by:

Date:

Serving Eastern Massachusetts

Referral Intake Forms

Personalized Care | Locally Owned | Walk-Ins Available

Personalized Care
Locally Owned
Walk-Ins Available

Mental Health Clinic Intake Form

Get in Touch With Us

NEW BEDFORD, MA

Serving Eastern Massachusetts

Referral Intake Forms

Personalized Care | Locally Owned | Walk-Ins Available

Personalized CareLocally OwnedWalk-Ins Available

Mental Health Clinic Intake Form

Get in Touch With Us

NEW BEDFORD, MA

Personalized Care
Locally Owned
Walk-Ins Available