(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
Appointment Request Form -Couple
*Please choose who will be the identified client / whose insurance will be billed. Provide the identified client's information in the top section. The second person's information will be entered in the bottom section. Thank you!
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
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Female
Transgender
Non-binary
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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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*Please provide non-identified client's information below, Thank You!
Email
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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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Days:
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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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Briefly describe why you are seeking counseling at this time.
(*)
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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.
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CAPTCHA (lower case letters only)
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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