(978) 535-1608 ext 1
main@nscliniciansgroup.com
North Shore Clinicians Group LLC est. 2011
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Appt. Request -Adult
Appt. Request -Child
Appt. Request -Couple
NSCG Appointment Request Form -Adult
*Please fill out the fields below and click on the "Submit Appointment Request" button at the bottom of the page. Thank you!
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Email:
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Mobile Phone:
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First Name
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Last Name:
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DOB:
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Gender
Male
Female
Transgender
Non-binary
Prefer not to respond.
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Street Address:
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City:
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State:
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Zip Code:
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Health Insurance
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Policy Number:
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Subscriber:
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Copay Amount:
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Previous Therapy
Currently seeing a therapist but want to see someone different.
Not currently seeing a therapist but have seen a therapist in the past 3 months.
I last saw a therapist more than 3 months ago.
I have never met with a therapist.
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History of Inpatient Psychiatric Hospitalizations
(*)
At least 1 inpatient admission in the past 3 months.
At least 1 inpatient admission in the past year.
Three or more previous inpatient hospitalizations.
No history of inpatient psychiatric hospitalizations.
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Current Medications
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Trauma History
(*)
History of childhood trauma.
History of adult trauma.
Traumatic event in the past year.
Previously been diagnosed with PTSD.
I believe that I have PTSD that has not been formally diagnosed.
No history of trauma.
Input required.
History of Addiction
(*)
Currently using.
Clean & Sober less than 3 days.
Clean & Sober less than 3 months.
Clean & Sober between 3-12 months.
Clean & Sober more than a year.
No history of addiction.
Required Field.
History of Legal Issues
(*)
History of legal issues.
Current legal involvement.
Current custody proceedings.
Counseling needed for proof of trauma, other psychological injury.
History of impulse control / violence.
No history of legal issues.
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Days:
(*)
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Please check the days that you are available for appointments. Thank you!
Times:
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Early Morning
Morning
Afternoon
After 3pm
After 5pm
Please check the time of day you are available. Thank you.
Detailed Availability:
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Telehealth/Video Sessions?
(*)
Only interested in telehealth sessions.
I prefer telehealth sessions.
I prefer in-person sessions.
Only interested in in-person sessions.
Field cannot be blank.
Briefly describe why you are seeking counseling at this time.
(*)
0/1000
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Request Appointment
Appt. Request -Adult
Appt. Request -Child
Appt. Request -Couple
(978) 535-1608 ext 1
main@nscliniciansgroup.com
North Shore Clinicians Group LLC est. 2011
