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.

MM slash DD slash YYYY
Name of person completing this form*
Patient's name*
MM slash DD slash YYYY
Street address, apartment/ unit number
City/ Town, State, Zip code
Are you using EAP (Employee Assistance Program) benefits through your employer?*
*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.
Max. file size: 100 MB.
Max. file size: 100 MB.
Are you the subscriber of the Insurance?*

If you are not the subscriber, please answer the following questions:

Do we have your permission to contact the subscriber regarding financial and/or insurance questions?*
Individual/Family/Couples counseling. Medication consultation (limited availability)
Would you be interested in attending a group?

Please answer the following questions to the best of your ability.

Has the patient been hospitalized for psychiatric reasons?
Does the patient have any drug or alcohol issues or concerns
Is the patient currently taking any psychiatric medications*
Are the services the patient is seeking regarding a workplace or automobile accident?*
Are the services the patient is seeking related to a legal matter?*
Is the patient involved in a custody situation?*

Responses will be sent by email. Please contact the office if you have not received a response within 5 business days.

This field is for validation purposes and should be left unchanged.