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  • NEW PATIENT QUESTIONNAIRE

    Time to Heal Me, LLC
    Alissa Dillon, LCMHC, LMHC, LPC, CPC
    14 Front Street • Suite 3-4 • Exeter NH 03848
    (978) 857-6549

  • Format: (000) 000-0000.
  • Date of birth:*
     - -

  • Your medical record is confidential will not be released to a third party without your approval unless:

    • You are at a risk of committing harm to yourself or another person
    • You are at risk of harm (abuse or neglect) by another person
    • You are experiencing a medical event and it is considered an emergency
    • You require emergency mental health screening and/or hospitalization.

    A release of information for an emergency contact may be requested.

  • *I understand failure to keep my scheduled appointment may result in termination of services. 

  • Please indicate any symptoms you have experienced during the past 1-3 months:*

  • THERAPY INFORMATION

  • HISTORY

  • Trauma history:*
  • Perpetrator:*

  • MILITARY/FIRST RESPONDER INFORMATION

  • Background

  • Please enter a whole number

  • PERSONAL INFORMATION

  • Marital status*
  • Substance use:*
  • Family history of substance abuse?*
  • How did you hear about Time to Heal Me/ Alissa Dillon?

  • Name of Insurance Company:

  • Insurance subscriber Name, DOB and Phone Number.
    Leave blank if you are the subscriber.

    PLEASE EMAIL or TEXT copies of your insurance card (front and back). AlissaD_Dillon@yahoo.com (978) 857-6549

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