• Intake Form

  • Client Data Sheet

  •  -  -
    Pick a Date
  •  -
  •  -
  • Medical Insurance Information

    (Skip this section if you are going to pay out of pocket)
  • If you are planning to use your insurance and you nswered "NO"; please go to the "Form's Page" of our website, relationshiprediscoverycenter.com, print off the "Insurance Guidance and Insurance Form". Clear guidance is provided for each steps for you to collect all the information you will need. You will need this information to determine if your insurance will cover these services and to deterrmine your cost.  This call reduces the chances of unexpected bills. As a reminder: you are responsible for the fees when these services are not covered by your insurance. 


  • At this time this office is unable to bill for Aetna, Maine Care, Medicare, Tricare. If you have these insurances, services are still possible by paying out of pocket. Fee reductions may be possible, see web site or call Bill.

  •  -
  • Emergency Contact

    If coming as a couple please list someone other than your partner.
  •  -
  • Medical Providers

    Please fill in available information
  •  -  -
    Pick a Date

  •  -  -
    Pick a Date
  • Medications

  • PHQ-9

    Depression screening: (Please note: The PHQ-9 and the GAD-7 look very much alike but have different questions)
  • Over the last 2 weeks how often have you been bothered by any of the following problems?

  • GAD-7

    Anxiety Screening: (Please note, The GAD-7 and the PHQ-9 look alot alike, however the questions are different.)
  • Over the last 2 weeks how often have you been bothered by any of the following problems?

  •  
  • Should be Empty: