North Shore Clinicians Group

Referral Form: Child | 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 -Parent:(*)

This is not a valid email address.

Phone -parent:(*)

Invalid phone number. Please enter a valid phone number. Thank you.

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First Name -Parent or Parents:(*)

Invalid Input

Last Name -Parent or Parents:(*)

Invalid Input

Family / Custodial Status(*)

Invalid Input

Legal Custody Status(*)

Can not be blank.

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First Name -Child(*)

Invalid Input

Last Name -Child(*)

Invalid Input

DOB:(*)

Gender

Invalid Input

Street Address:

Invalid Input

City:

Invalid Input

State:

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Zip Code:

Invalid Input

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Health Insurance(*)

Invalid Input

Policy Number:(*)

Invalid Input

Subscriber / Subscriber DOB:(*)

Invalid Input

Copay Amount:(*)

Invalid Input

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

0/1000

Invalid Input

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Preferred Session Format(*)

Telehealth only.

Primarily prefers telehealth.

Primarily prefers in-person sessions.

In-person only.

Invalid Input

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CAPTCHA (lower case letters only)(*)

CAPTCHA (lower case letters only)

Invalid Input