Mental Health New Client Form
Please complete this brief intake form so Blue S.E.A.S can review your request, contact you about services, and place you on the waitlist if services are not immediately available.
Important:
Submitting this form does not establish a therapeutic relationship or guarantee services. If you are experiencing a mental health emergency, please call or text 988 or go to your nearest emergency room.
Client Information
Client Full Name
*
First Name
Middle Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Age
*
Guardian Name (if under 18)
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
Preferred Method of Contact
*
Phone
Email
Either
Service Request
What Services Are You Seeking?
*
Individual Therapy
Group Therapy (Emotion Regulation, Relationship Boundaries, Grief Processing, etc.)
Family Therapy
Not Sure/Need Guidance
Briefly describe your primary concerns or reasons for seeking services:
*
Safety Screening
Are there any immediate safety concerns?
*
Yes (harm to self or others, unsafe behaviors)
No
If yes, briefly describe your concern(s)
If you indicated immediate safety concerns, please seek support right away by calling or texting 988, contacting your local crisis center, or going to the nearest emergency room. Blue S.E.A.S will review your request, but this form is not monitored for emergencies.
Insurance / Payment
Payment Type
*
MassHealth
Private Insurance
Private Pay
Not sure
Insurance Provider
Availability
What days are you generally available?
*
Weekday mornings
Weekday afternoons
Weekday evenings
Weekends
Preferred start timeframe
*
As soon as possible
Within 1 month
Flexible
Consent & Acknowledgment
Consent to be contacted by Blue S.E.A.S regarding services
*
I agree to be contacted by Blue S.E.A.S regarding services
Acknowledgment of service limitations
*
I understand this form does not establish a therapeutic relationship and does not guarantee services
Submit Request
Should be Empty: