top of page
Blue Abstract Background

Let's Get Started

We are excited to start working with you on your mental health journey. Please fill out the form below and we will be in touch within 24 hours to schedule you with a provider. 

Please fill out the below form

All fields marked with asterisks (*) are required.

General Referral Information:

I am referring FOR:
Myself
My Child
A Family Member
A Friend
A Patient
Other
Type of Service seeking:

† Please note the Diagnostic Differential is NOT a Neuropsychological Test.

We do not offer Neuropsychological Testing.

Referred to us by:

~ ~ ~

Client & Contact Information and Concerns:

* Client's Birthday:
Month
Day
Year

Only for someone referring for someone else, i.e: Parents/Legal Guardians referring their children.


For minors that do NOT have their own emails, put the parent/guardian's email here.

If you're referring for someone else, put your email here. Unless you are referring for a minor, then put the parent/legal guardian's email under the client email.

You may skip this if referring for a minor that does NOT have their own phone number.

If you're referring for anyone other than yourself, put your phone number here.

This space is intended for anything extra you want to add such as extra contacts to add to the client's chart/special emergency contacts, or if you just ran out of space under "Primary Concerns" and need more room to continue, but anything you think will be helpful that isn't covered elsewhere in the form may go here.

~ ~ ~

Insurance Information:

* Insurance Carrier:

If you selected "Other" from the Insurance Carrier Dropdown above, please specify who your plan is with and provide a picture of the front and back of your insurance card below.


Uploading pictures of your insurance card allows us to do a pre-verification on your coverage to avoid potential issues.


If your insurance is not one we take, we do have reduced-cost options with interns. You may select interest in this in the Appointment Type Preference options below.


Multi-line address

~ ~ ~

Preferences, Availability & Special Needs:

Clinician Gender Preference:
* Preferred Clinician:

Choose a clinician that interests you to work with, or select "Unsure / No Preference" if you do not know at this time or are open to suggestion.

Please note that ONLY clinicians currently accepting new clients will have their name available in the list.

~ ~ ~

Preferred Days Availability (select all that apply)
Preferred Hours Availability (Select all that apply)

Use the above box for any additional information if your availability is more complicated than simply "M/T/W evenings". For example: "I can do Mondays before noon, Tuesdays any time, Wednesdays after 5p, but not Thursdays or Fridays."

~ ~ ~

Appointment Type Preference:

~ ~ ~

Location Preferences

Please note that not all clinicians are available at all locations

and some locations have more limited availability than others.



This only applies for in-person appointments. If your preference is for telehealth you may skip to the next section.

Dropdown

~ ~ ~

How would you like us to contact you/the referred client?

~ ~ ~

Special Needs / Accommodations:

While the main building is wheelchair accessible, the second and third floors are not, and stairs are steep. If you need accommodations to stay on the first floor, simply check the mobility box to let us know.


Visit Us

Our office is on the border of Massachusetts and Rhode Island.  Our practitioners see clients virtually and in-person, as deemed necessary. 

Phone

(774) 314 -1215

Fax

(774) 220- 5909

Locations

Main Office - Central Massachusetts

61 Main St., Blackstone, MA 01504

​

Satellite Office - Southern Massachusetts/Rhode Island

70 Case Ave, Office #3 , Seekonk, Massachusetts 02771


​

Appointments

Hours of Operation  - by appointment only

In-person and telehealth available

Main Office - Blackstone, MA
Satellite Office - Seekonk, MA

Insurance & Private Pay

We accept most major private insurance companies. Please check your specific insurance policy for behavioral health coverage. We also accept private patients. Unfortunately, we do not accept Cigna, Neighborhood Health Plan, MassHealth products, including Medicare, or Medicaid at this time. If you are a student, we offer reduced rates based on need.

Evaluations & Prescriptions

Please note, we do not provide forensic evaluations or neuropsychological / psychological evaluations.  We also do not prescribe medications. Please consult your primary care physician.

bottom of page