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 codeAre you using EAP (Employee Assistance Program) benefits through your employer?* Yes* No *Not all of our clinicians accept EAP or are paneled with all EAP companies. The patient must provide Atlantic Counseling the EAP company name, confirmation number and number of sessions prior to receiving services. If the office is not notified prior to receiving services then we will be unable to bill your EAP provider for sessions that have already occurred.Insurance 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.PhoneThis field is for validation purposes and should be left unchanged.