Appointment Request Form

Appointment Request Form

Thank you for providing the information below. This form is HIPAA-compliant, and will help us determine whether we are a good fit for your current needs.
Please note that this form is not continuously monitored and should not be used to seek urgent or emergency psychiatric care. If you are experiencing a psychiatric emergency, having thoughts of harming yourself or others, or feel unable to maintain your safety, call 911, go to your nearest emergency department, or contact the 988 Suicide & Crisis Lifeline by calling or texting 988.
Demographic Information
Patient Name

First NameLast Name
Patient Date of Birth

MonthDayYear
Email Address
Phone Number
Are you completing this form for yourself or for someone else?
Clinical Information

Please note that Shore Pine Psychiatry may not be the right fit for individuals experiencing active suicidal ideation, acute psychosis or mania, active substance use requiring detoxification with medical monitoring, or active eating disorder symptoms requiring higher level of care.
What brings you to seek care at this time?
Please indicate which concerns you would like to be evaluated and/or treated for:

Other
Have any of the following occurred within the past year?
Are you currently working with a therapist?
Insurance

Shore Pine Psychiatry is currently in-network with Blue Cross Blue Shield (BCBS) and Point32Health (Harvard Pilgrim / Tufts Health Plan).
Do you plan to use insurance?
If you plan to use insurance, please select the name of your in-network carrier (if applicable):
Member ID:
Policyholder Name:
Policyholder Date of Birth:
Relationship to Patient:
Additional Information
Provider Preference
How did you hear about us?
Anything else you would like us to know?
Should be Empty:

Appointment Request Form

Demographic Information

Clinical Information

Insurance

Additional Information