Boston Psychiatry Center - Appointment Request Form

Who is filling out this form?*

Patient/GuardianProvider/Practice Representative

Referrer Name*

First NameLast Name

Referrer Organization*

Referrer Email Address*

Confirmation Emailexample@example.com

Referrer Phone Number*

Attachments

For example, discharge summary, progress note, or anything else that might be helpful for care coordination.

Please notify the patient about this referral prior to this submission so that we may contact them directly.

Patient Name*

First NameLast Name

Patient Date of Birth*

MonthDayYear

Today's Date*

Date

Hour MinutesAM/PM Option

Age Confirmation*

Please review and make sure this is the correct age of the patient. If not, please correct the date of birth.

Parent/Guardian Name*

First NameLast Name

What is the patient's (or guardian's) email address?*

Confirmation Emailexample@example.com

What is the patient's (or guardian's) mobile phone number?*

When is the best time to reach you?*

e.g., "Monday, Tuesday, or Friday before 12pm."

Reason for Seeking Services*

Which services have been recommended to you?*

Outpatient Therapy or PsychiatryIntensive Outpatient ProgramPlease help me decide

What services are you looking for?*

Individual TherapyPsychiatryHelp Me Decide

How did you hear about us?*

Please Select Your Insurance Carrier*

Name of Insurance*

Acknowledgement

We are in-network with Harvard Pilgrim, Aetna, and UnitedHealthcare Student Resources (Harvard Pilgrim) insurance plans. If we are out-of-network with your plan, you can still be seen here. Many PPO and POS plans cover a large portion of visit costs. We’ll submit the claim on your behalf so you only pay your share (your coinsurance).

Click here for our out-of-network rates. Contact our clinic if you have questions.

Please check the following the box to acknowledge that you have read the above statement.*

Acknowledge

Please Note

If we do not accept your insurance and you are interested in Single Case Agreements, please contact us at (617) 468-5048 or info@bostonpsych.org.

You can learn more here.