Intake Survey

PLEASE NOTE: Our Cambridge office is now closed.

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By completing this form on-line and submitting it upon completion, you are acknowledging and accepting the risk that this information may not be secure.

This survey will take no more than 10-15 minutes to complete. It is intended to be an easy way for you to give us the information we need to determine how best to help you. Thank you for taking the time to fill us in.

Question Title

* CLIENT IDENTIFICATION. Please enter the following information about the individual who is seeking services:

Name

Address

City, State

Zip code

Phone

Cell

Date of birth

Gender

Age

Grade:

Question Title

* If the client is a child or adolescent, please provide information about the parent or caretaker requesting services.

Parent/Caretaker Name

Relationship to client

Address (if different from above)

City, State

Zip

Phone

Cell

Email Address:

Question Title

* Please provide the date of your or your child's most recent visit to a primary care physician.

Question Title

* Please indicate your health insurer. The plans shown are the only ones we accept. Please note that though we accept Tufts, we do not participate with Tufts GIC or Tufts Navigator or Tufts RI Together. If you have a plan we do not accept, you may choose to pay out of pocket or self pay.

Question Title

* Please provide us with information about your insurance coverage:

Provider or customer service phone number (on back of card)

Subscriber name:

Subscriber date of birth:

Member ID#

What state is your policy from?

Question Title

* We strongly recommend that you determine whether or not your insurer requires that you get a referral from your primary care physician before obtaining any psychological services. If a referral is required, and you do not obtain one, you will be personally responsible for all fees for services we provide to you. Please indicate below that you understand this and agree.

I understand and agree that I am financially responsible.

Question Title

* Who referred you to our center, or how did you learn about our center?

Web search/internet

Facebook

Public presentation

Friend or family

Referral by a professional

Who referred you?

Question Title

* What is the primary or main service you are seeking?

25% of survey complete.