Aspire ADHD Contact Form

Consultation Request
We typically respond to inquiries within 24-48 business hours. If you need immediate assistance, please call our office at (617) 991-9151 during business hours.

If you or loved one is experiencing a psychiatric or medical emergency, please call 911 or head to the nearest emergency room. Please note that we are not a crisis or urgent care facility.
Full Name

First NameLast Name
Date of Birth

MonthDayYear
Date
What is the age of the person seeking services?
Scheduling for yourself or other? (if other, please indicate relationship)

Other
What state will you be physically located in during your appointments?
Preferred method of contact
Phone Number
Format: (000) 000-0000.
Email
By providing your email address, you agree to receive communication from Aspire Medical Group regarding your care, appointments, and billing. Email may not be fully secure.
Optional SMS Communication Consent
- Message frequency varies. Message and data rates may apply.
- Consent is optional and is not a condition of receiving services.
- Your mobile information will not be sold or shared with third parties for marketing purposes.
- Reply STOP to opt out at any time. Reply HELP for assistance.
What type of ADHD service are you seeking?
Have you previously been diagnosed with ADHD by a healthcare provider
When were you diagnosed with ADHD, and what type of provider made the diagnosis
If seeking ADHD medication management, can you provide medical records documenting your ADHD diagnosis or prior treatment?
Are you currently taking, or have you previously taken, medication for ADHD?
If applicable, please list any current or previous ADHD medication(s), dosage(s), and prescribing provider, if known.
Are you currently prescribed any controlled medications other than ADHD medication?
Do you currently use marijuana or other recreational substances?
Have you been diagnosed with any other mental health conditions?
If yes, please list the condition(s).
Are you currently experiencing thoughts of suicide, harming yourself, or harming someone else?
Are you willing to complete medical records review, prescription monitoring, testing, labs, urine drug screening, ECG, or in-person visits when clinically indicated?
What are your main concerns or goals for seeking ADHD services?
How did you hear about us?

Other
INSURANCE INFORMATION

Your insurance will not be billed at this time. This information is collected solely to verify your eligibility and benefits for services under your plan.
Do you plan on using insurance?
Primary Insurance
Member's Full Name

First NameLast Name
Member ID/Insurance ID Number
Member's Date of Birth

MonthDayYear
Date
Relationship to Subscriber
Subscriber Full Name

First NameLast Name
Subscriber's Date of Birth

MonthDayYear
Date
Do you have a Secondary Insurance plan?
Secondary Insurance ID Number
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Consultation Request

INSURANCE INFORMATION