Boston Psychiatry Center - Appointment Request Form

Appointment Request Form
Patient Name*

First NameLast Name
Patient Date of Birth*

MonthDayYear
Today's Date*

MonthDayYear
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 your email address?*

Confirmation Emailexample@example.com
What is your 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 accept Harvard Pilgrim, Aetna, and UnitedHealthcare Student Resources (Harvard Pilgrim) insurance plans. Patients with other insurance plans are responsible for our private pay rates. We can provide a superbill to support out-of-network reimbursement.
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.
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