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Client Profile Form
Client Information
Client First Name
*
Client Last Name
*
Preferred Name
Client Phone Number
*
Client Email Address
*
Client Gender
Male
Female
Non-Binary or Transgender
Is the Client a Minor?
Yes
No
If client is school aged, what school district are they enrolled with?
Date of Birth
*
Age
*
Other Pronouns
Pronouns
He/Him
She/Her
They/Them
Other
Contact Information
(if different from client)
Contact's First Name
Contact's Last Name
Contact Phone Number
Contact's Email
If you are contacting on behalf of the client, have they agreed to therapy?
Yes
No
I’m waiting to find a therapist before speaking with the client
Therapy is mandated by court of legal authority
Reasons for seeking Therapy (Choose all that Apply)
Depression
Anxiety
Transition/Life Changes
Trauma
Personal Relationships
ADHD
Identity (gender or sexual)
Personal Wellbeing/Improvement
PTSD
Substance Use or Addiction
Eating Disorder
Recent Discharge from a Hospital
Autism
Conduct/Behaviour Issues
LGBTQ (you would like to be placed with a therapist who is part of or specialzes in the LGBTQ community)
Specific Phobia (Please click here and elaborate by clicking other and giving more information in the text box)
Other
Please Type Other Reason Here
Therapy Preferences (choose all that apply)
Telehealth/Secure Therapy by Video (Anywhere in MA)
In Person in Yarmouth Port
In Person in Bourne
My Preference is for in person but I'm willing to use Telehealth if necessary
I ONLY wish to be seen in person
I am open to seeing a male or female therapist
I ONLY wish to be seen by a male therapist
I ONLY wish to be seen by a female therapist
I am requesting a specific therapist but am willing to see another
Therapist you are requesting to see:
I'm open to seeing any available Therapist
Amy Griffin
Amy Leek
Cameron McCauley
Charlene Flynn
Charlotte Coe
Danielle Lally
Haleigh Creamer
Heather Skutnik-Sheffield
Jaclyn McMurray
Jamie Jackson
Katie Fauth
Liz Freedman
Meridith Wirtz
Rachel Feddor
Rebecca Rubenstein
Robert Mudge
Samantha Johnson
Sarah Kristy
Shannon Devaney
Victoria Martin
No elements found. Consider changing the search query.
List is empty.
Client's Availability for Sessions (choose all the apply)
*
Nearly Always Available/Will try to make any time work
Week Days 8AM to 3PM
Week Days 3PM to 6PM (limited availability)
Week Days 6PM to 8PM (limited availability)
Weekends
Other
Please specify other time here
What insurance company do you use? (These are the insurance companies we are in-network with)
Blue Cross Blue Shield
Harvard Pilgrim
Tufts
Tufts Public
United Healthcare
MGBHP Mass General Brigham Health Plan (EPO, PPO, HMO only)
Self Pay
Other
Please Specify Other Insurance here
Other Insurance Carrier
Anything else we should know?
Would you like us to verify your insurance now?
Yes
No
Insurance Company Listed on Your Card
Member ID#
Plan (if you see it on your card)
Group Number (if you see it on your card)
First Name (EXACTLY as it appears on your card)
Middle Name or Initial (EXACTLY as it appears on our card)
Last Name (EXACTLY as it appears on your card)
Name and DOB of CARD HOLDER (if not self)
Upload a Picture of the Front of your Card (preferred but not necessary)
Upload a Picture of the Back of your Card (preferred but not necessary)
Submit
