New patient Intake Form If you are interested in becoming a patient, fill out the form below. I will reach out to you soon to see if we would be a good fit. Looking forward to hearing from you! Patient Name * First Name Last Name Patient DOB * Form Completed By * First Name Last Name Phone * (###) ### #### Email * Address * Please note, I practice exclusively in Massachusetts Insurance Plan Name * Patient Insurance ID Number * Insurance Subscriber * Are you taking any medications or supplements currently? * Please include any prescribed, OTC medications, and supplements Do you have a current therapist? * If so, please include their name and phone number How can I help? * Please list past diagnosed psychiatric conditions or symptoms you are struggling with. Also, include if you have any past hospitalizations for a psychiatric concern along with anything else you feel would be helpful for me to know. How did you hear about us? Thank you!
