North Shore Clinicians Group

Referral Form: Adult | North Andover

*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:(*)

Gender

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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 / Subscriber DOB:(*)

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Copay Amount:(*)

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Previous Therapy

Currently engaged in therapy with another provider.

Not currently in therapy, but received services within the past 3 months.

Last received therapy services more than 3 months ago.

No prior therapy experience.

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Inpatient Psychiatric History(*)

At least one inpatient admission in the past 3 months.

At least one inpatient admission in the past year.

Three or more previous inpatient hospitalizations.

No history of inpatient psychiatric hospitalization.

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Current Medications

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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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Briefly describe why you are seeking counseling at this time. (*)

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CAPTCHA (lower case letters only)(*)

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