Initial Screening Form

Welcome to Infinite Routes, LLC!

We are a therapy practice located in Needham, Massachusetts.

We understand that life can be challenging and that there are times when we can all use extra support. Infinite Routes, LLC provides children, teens, and young adults with a safe space to grow, feel accepted, and explore their feelings.

To get started and learn more about our services, please complete the form below. This screening tool will help us to understand what supports you are looking for and determine how to best support you. Once you have submitted the form, you can expect to receive an email from connect@infiniteroutesllc.com in the near future!

Please note that all mental health professionals are mandated reporters. This means that all Infinite Routes, LLC staff are required by law to file a report on any known or suspected abuse and/or neglect.

Name of Person Completing Form

First NameLast Name

Pronouns

Relationship to Client

Self, Parent, Guardian, etc.

Phone Number

Area CodePhone Number

Email

example@example.com

Who are you seeking services for?

My Child, Myself, etc.

Client's Name

First NameLast Name

Client's Legal Name, if different (for insurance purposes only)

First NameLast Name

Client's Pronouns

Client's Age

Parent/Guardian 1 Name: (for minors)

Parent/Guardian 1 Phone Number:

Parent/Guardian 1 Email:

Parent/Guardian 2 Name: (for minors)

Parent/Guardian 2 Phone Number:

Parent/Guardian 2 Email:

Town/City of Residence

Client's Preferred Mode of Communication

Client's Primary Language

Other languages used at home

What services are you interested in?

Individual TherapyGroup TherapyGuardianship

What services are you interested in?

Individual TherpayGroup TherapyGuardianship

Client Diagnoses/Medical Conditions

Please acknowledge that you are aware that Infinite Routes, LLC is an out of network provider for all services

Yes, I acknowledge that Infinite Routes, LLC is an out of network provider for all services

If your health insurance plan accepts out of network providers, will you be seeking reimbursement through your plan? Please contact your insurance provider regarding coverage.

YesNo

Please provide a brief description of why you are seeking services at this time

Please list your top 3 goals for services

Please describe what you are looking for in a therapist (personality, energy level, approach, etc.)

Share any necessary accommodations or sensory preferences for the client:

Has the client participated in therapy previously?

NoYes, Individual TherapyYes, Group TherapyYes, Currently in Therapy

Please acknowledge that you are aware that payment is required at the time of each service

Yes, I acknowledge that payment is due at the time of services