Initial Interest Form (Adults)
Please complete this form to provide more information about the services in which you are interested (for yourself or your adult child). Once it is submitted, an intake coordinator will contact you within 5 to 10 business days.
Client's Name
*
Client's Date of Birth
*
-
Month
-
Day
Year
Client's Gender
*
Male
Female
Other
Primary Phone Number
*
Secondary Phone Number
Please enter a valid phone number.
Email
*
example@example.com
Home Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
What services are you interested in? Please check all that apply.
*
Individual therapy
Couples therapy
Family therapy
Psychiatry (age limit: 21 years old)
Psychological Evaluation for autism spectrum disorder
Psychological Evaluation for another disorder (examples: ADHD, learning disorder, anxiety, depression)
Please note: you have indicated that you are older than the age limit for psychiatry services.
If you are interested in seeing Dr. Paoletti at his other practice, where there is no age limit, please visit https://psychiatryassociatespc.com/.
What concerns are leading you to seek these services?
*
0/200
Have you undergone a previous evaluation for these concerns?
*
No
Yes
Please upload previous evaluations and/or other relevant documents.
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Insurance Company
*
Insurance coverage is subject to provider plan and treatment.
Who completed this form?
Client/self
Spouse/Partner
Caregiver/parent
Other
Spouse/Partner Name
First Name
Last Name
Caregiver/Parent Name
First Name
Last Name
Do you have legal guardianship over client?
Yes
No
Other
Please upload guardianship paperwork as applicable.
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Is there anything else you would like us to know?
0/200
Submit
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