New Patients

In the upcoming weeks we will secure this page so you can be able to give us the following information safely over the internet. For now, please call our main number and leave the necessary information. Thank you.

Referral Form

* indicates required field

* Service (select one)	Psychotherapy - Adult Psychiatry - Adult	Psychotherapy - Child Psychiatry - Child
Today's Date
Referred by

Patient Information
* Patient Name
Parents (if applicable)
* Address 1
Address 2
* City
* State
* Zip Code
* DOB	/ /
* SSN	- -
Preferred method(s) of contact:
Home Phone *
Work Phone
Cell Phone
Email
Best time to call:

Policy Holder Information
* Name
* Insurance Company
* Policy #
* DOB	/ /
* SSN	- -

* Therapy Requested: Individual Family Couple
Referral Problem (Description of Current Problem(s))

Preferred Day(s) and Time(s)

The following questions may not apply to you, but please answer them to the best of your ability.
Yes	No
		Have you ever attended therapy before?
		If so, with whom and when?
		Have you ever been treated by a Psychiatrist or a Nurse Practitioner?
		If so, where and when?
		Reason?
		Have you ever been hospitalized for psychiatric reasons?
		If so, where and when?
		Reason?
		Are you on any psychiatric medication(s)?
		If so, please list:
Yes	No
		Do you have any domestic violence issues?
		Do you (or your partner) have any substance use/abuse issues?
		Do you (or your partner) have any legal issues?
		If yes to any of the above, please explain:
		Do you (or your partner) have any custody issues?
		If yes, please explain:
		Is there any outside agency involvement? Yes No
		If yes, what agency (ex: DSS, Mass Rehab, Family Services)
Yes	No	May the therapist leave messages for you regardingAtlantic Counseling...
		...on your voicemail at home?
		...on your voicemail at work?
		...on your voicemail on your cell?