Inquiry Form

1
What is your first name?* This field is required.
2
Which best describes what you are looking for?* This field is required.If you're not sure, please click here to determine what kind of therapy is right for you. If you need additional support in selecting the right kind of therapy, you can provide a description of your current situation at the end of this form and we'll get back to you with our recommendation. For now, please select which best describes what you are looking for.
Individual Therapy
Couples Therapy
Family Therapy
3
Do you have insurance?* This field is required.
YESNO
4
Does your partner have insurance?* This field is required.To find out whether or not we take your partner's insurance, please click here. For couples therapy, we require that both partners provide their insurance information. Sessions are billed as two 38 minute sessions, one to each partner’s insurance plan. So, the cost of the session will be your two copays or your percentage of what your insurance plan isn’t covering. If using insurance, we will ask you to provide your insurance information so that we can run your benefits and notify you how much your insurance is going to cover and if there is any deductible that needs to be met.
Yes, they are on the same plan as me.
Yes, they have their own insurance plan.
No, they do not have insurance.
5
Before you enter your insurance information...

Please note that we accept the following plans.

All Blue Cross Blue Shield plans (Anthem, Empire, etc.)

United Healthcare (United Behavioral Health, Harvard Pilgrim, Optum, etc.)

Allways

UMR

Oxford

Health Plans Inc.

Tufts Commercial

etc.

We do not accept the following plans.

Tricare

Medicare

Mass Health

Tufts Health Direct

Tufts Public Health

Health Connector or Commonwealth Care Plans

Health New England

Beacon

etc.

You may have out-of-network benefits with the following plans.

Unicare

Cigna

Consolidated Health Plans

Wellfleet

Aetna

GIC

etc.

If you're not sure whether we take your insurance or what to do if you and your partner have different insurance plans, please continue and we will verify your benefits. You may ask any questions at the end.
6
If both of you are on the same plan, please provide your insurance information below.
7
{name}, please provide your current insurance information below.If your partner has a different insurance, you will be required to enter that next. If you are seeking individual therapy, you are only required to enter your own insurance information here.
8
Please provide your partner's current insurance information below.
9
When would you be available for appointments?We offer appointments 7 days a week in the mornings, afternoons, and evenings. The more flexibility there is in your schedule, the more appointments we are able to offer.
Huge
Large
Normal
Small
Ok
Ok
10
Are you in a crisis?
YESNO
11
Would you be interested in an intensive?Note: Intensives are not a service covered by insurance and have a range of rates and payment plans. For partners ready to put in a big effort to make their relationship work, we offer various intensive therapies. This presents a unique opportunity for each partner to dig deep into the cycle of conflict that has kept them stuck for years or a crisis that has arisen. This helps them take strategic steps to transform their relationship. Typically, intensives or mini intensives are offered with either one of the directors, Donna Gilman and Katherine Waddell. Please take a look at our short video explaining the intensive process here. If you are interested in hearing more, one of the directors can give you a call to discuss the various options right away.
YESNO
12
How can we help you in your current situation?We will be using this information to match you with one of our excellent clinicians. While there is no limit to how much you can write, we suggest providing only a few lines for now given that we review multiple forms each day. You can describe your situation in further detail later when submitting your paperwork to the clinician. If you have any questions about the process or have preferences for a clinician, please list them below and we will get back to you.
Huge
Large
Normal
Small
Ok
Ok
13
If we need to contact you with follow-up questions, which is the best number for us to call?
Area Code
Phone Number
14
Please enter your email.* This field is required.We will send you an introduction email regarding our policies so that you know what to expect ahead of time.
example@example.com
Should be Empty: