Appointment Form for New Patients "*" indicates required fields Please complete this form if you would like to be a new patient with Atlantic Counseling. We are offering Telehealth services to new and active patients.Date* MM slash DD slash YYYY Name of person completing this form* First Last Email Address* Best phone number*Patient's name* First Last Patient's date of birth* MM slash DD slash YYYY Patient's address (Please note that you must be a Massachusetts resident in order to be seen by our clincians)* Street address, apartment/ unit numberPatient's address* City/ Town, State, Zip codeInsurance company(primary)* Policy Number* Please upload a copy of your insurance card.*Max. file size: 100 MB.Insurance company ( secondary, if applicable): Policy number (secondary, if applicable): Please upload a copy of your insurance card.Max. file size: 100 MB.Are you the subscriber of the Insurance?* Yes No If you are not the subscriber, please answer the following questions:Subscriber name: Subscriber's phone number:Subscriber's email address: Do we have your permission to contact the subscriber regarding financial and/or insurance questions?* Yes No Service Requested* Individual/Family/Couples counseling. Medication consultation (limited availability)Would you be interested in attending a group? Yes No Maybe Any preference in meeting with a male or female clinician?---Select---MaleFemaleNo PrefefrenceWhat time of day are you available for appointments? Please note that we only offer Telehealth appointments at this time. Reason for seeking services.* Please answer the following questions to the best of your ability. Has the patient been hospitalized for psychiatric reasons? Yes No Please specify hospital name, date(s) and reason or N/A if doesn't apply.*Does the patient have any drug or alcohol issues or concerns Yes No Please explain issues/ concerns or N/A if doesn't apply.*Is the patient currently taking any psychiatric medications* Yes No Please list medications, doage and name of the prescriber or N/A if doesn't apply.*Are the services the patient is seeking regarding a workplace or automobile accident?* Yes No Are the services the patient is seeking related to a legal matter?* Yes No Is the patient involved in a custody situation?* Yes No Responses will be sent by email. Please contact the office if you have not received a response within 5 business days.NameThis field is for validation purposes and should be left unchanged.