Therapy Appointment Request Form
Patient's Name
*
First Name
Last Name
Date of Birth
*
Please select a day
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Day
Please select a month
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Please select a year
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Year
Gender
*
Please Select
Male
Female
Non-Binary
Not willing to Disclose
Other
Cell Phone Number
*
Patient's Email:
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Patient's Insurance Name
Patient's Insurance Policy # / Member #:
If the patient is under the age of 18, please complete the Parent / Legal Guardian section below.
Parent / Legal Guardian's Name
First Name
Last Name
Parent / Legal Guardian's Name
Please enter a valid phone number.
Parent / Legal Guardian's Name
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Parent / Legal Guardian's Name
example@example.com
Are you currently being seen by a Vendetti Wellness Group provider?
*
Yes
No
What type of therapy services are interested in?
*
Individual Therapy
Family Therapy
Couples Therapy
Are you interested in? (Check all that apply)
*
Virtual / Telehealth Sessions
In-Person Mansfield, MA
In-Person Hopkinton, MA
In-Person Framingham, MA
No Preference, First Available Location
Other
If "Other" is selected above, please specify:
Please select all reasons you are seeking therapy services:
*
ADHD
Anger management
Anxiety
Autism Spectrum Disorder
Bipolar
Depression
Family Issues/Dynamics
Grief and Loss
Gender Identity
OCD
Parenting
Postpartum
Relationships
Self-esteem and confidence
Stress Management
Substance Use
Trauma/PTSD
Work-related stress
Medication Management Services
Other
If "Other" is selected above, please specify:
Do you have any additional information you would like to share?
If you were referred, please specify who referred you to VWG:
Consent to Treatment, Billing, and Financial Responsibility:
By submitting this form, I consent to receive mental health services from Vendetti Wellness Group. I authorize Vendetti Wellness Group to bill my insurance for services provided and understand that I am financially responsible for any charges not covered by insurance, including copayments, deductibles, or denied claims. I also acknowledge that I may be charged a late cancellation or no-show fee in accordance with the practice’s policy if I miss or cancel an appointment without sufficient notice. I understand that fees for new patient appointments typically range from $175 and up, depending on the length of the session, complexity of services, and/or diagnosis. I acknowledge that additional consent forms and documentation will be required prior to scheduling an appointment.
Patient's Signature
Parent / Legal Guardian's Name
Continue
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