Consultation Request Form for Referral

Request a Consultation

Please complete this form and a client care coordinator will reach out to you in an effort to pair with with a therapist who best meets your needs.
Patient Demographics
Patient Name*

First NameLast Name
Patient Date of Birth*

MonthDayYear
Patient Address*

Street Address

Street Address Line 2

CityState

Zip Code
Contact Number:*

Area CodePhone Number
Can we leave you voicemail at the number above?*

YesNo
When would be the most ideal time to contact you?*

As Soon as PossibleWeekday mornings (7-11)Weekday afternoons (11-4)Weekday evenings (4-8)Weekends
Patient E-mail*
Can we contact you via the email address above?*

YesNo
Have you ever been a patient/client at Granite Pond before or have you ever been treated by one of the clinicians affiliated with Granite Pond?*

YesNoI'm not sure
Who at Granite Pond treated you before?*
Approximately when were you seen previously at Granite Pond or by one of the clinicians in the Granite Pond Group?*
Enter a date as best you can remember it.
Sex Assigned at Birth*

MaleFemaleOther
Current Gender Identity*

MaleFemaleTrans Male/Trans ManTrans Female/Trans WomanGenderqueer/Gender Non-conformingOther
Is the patient a minor, ward, or under any kind of guardianship?*

YesNo
Type of Guardian Relationship*

Parent in Legal Custody of a MinorDepartment of Children and FamiliesAdult Guardianship or ConservatorshipMinor/Child Guardianship or ConservatorshipRogers GuardianshipEmergency Guardian ProxyOther
Name of Parent/Guardian*

First NameLast Name
Is the Guardian's Contact Information the same as the Patient's Contact Information?*

YesNo
Guardian Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Guardian Phone*

Area CodePhone Number
Guardian Email*
example@example.com
Who is filling out this form?*

I'm filling out the form for myselfSomeone else is filling out this form on behalf of the patient
Name of Person Filling Out Form*

First NameLast Name
Please Specify Relationship to Patient...*
Tell us what you're looking for
I'm interested in...*

Counseling/Psychotherapy (most people select this option)Counseling, Court-OrderedForensic EvaluationOther
Type of Treatment...*

Individual CounselingCouples CounselingFamily Counseling
How would you prefer to engage in treatment (select all that apply)?

Remote Services via Secure Online VideoFace-to-Face Services in one of our officesHome-Based TreatmentOther
Which practice location works best for you?*
Clinicians are available who speak Spanish (Boston and Canton), Portuguese (Boston), and Korean (Boston)--which language would you prefer...?*

EnglishSpanishPortugueseKorean
I'm most available on... (a clinician may still offer you times outside this window)*

Weekday mornings (7-11)Weekday afternoons (11-4)Weekday evenings (4-8)Saturdays
Briefly describe what you hope to accomplish in counseling or evaluation*
Is there anything else we should be aware of prior to following up with you?
Payments and Insurance
Insurance Information*

Self-Pay (you pay cost of therapy directly)Reimbursement (you pay at time of service and you submit receipt to your insurance company)In-Network Insurance (When you provide your insurance info, we will verify if you are eligible for in-network benefits)Out-of-Network Insurance
Insurance Provider*
Insurance ID/Policy Number*
Provider or Member Services Phone Number (usually on back of card)*

Area CodePhone Number
Should be Empty:

Request a Consultation

Patient Demographics

Tell us what you're looking for

Payments and Insurance