PLEASE NOTE: Our Cambridge office is now closed.

Although the information you give here is secure through SSL encryption and meets government (HIPAA) requirements for privacy and security, please be aware that we cannot GUARANTEE privacy. If you prefer, you may give us this information by telephone by calling 401 351-7779 ext 100.

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.

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

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

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

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* Please provide us with information about your insurance coverage:

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* 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.

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

 
25% of survey complete.

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