Request a Consultation
Please complete this form to request a consultation and potential treatment with one of our clinicians. The information you supply will help us determine how best to address your needs, and is confidential.
Patient Demographics
Patient Name
*
First Name
Last Name
Patient Date of Birth
*
Please select a month
January
February
March
April
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December
Month
Please select a day
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Day
Please select a year
2024
2023
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Year
Patient Address
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Contact Number:
*
-
Area Code
Phone Number
Can we leave you voicemail at the number above?
*
Yes
No
Patient E-mail
*
Have you ever been a patient at this practice before of have you ever been treated by one of the clinicians in this group?
*
Yes
No
I'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
*
Male
Female
Other
Current Gender Identity
*
Male
Female
Trans Male/Trans Man
Trans Female/Trans Woman
Genderqueer/Gender Non-conforming
Other
Is the patient a minor, ward, or under any kind of guardianship?
*
Yes
No
Type of Guardian Relationship
*
Parent in Legal Custody of a Minor
Department of Children and Families
Adult Guardianship or Conservatorship
Minor/Child Guardianship or Conservatorship
Rogers Guardianship
Emergency Guardian Proxy
Other
Name of Parent/Guardian
*
First Name
Last Name
Is the Guardian's Contact Information the same as the Patient's Contact Information?
*
Yes
No
Guardian Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Guardian Phone
*
-
Area Code
Phone Number
Guardian Email
*
example@example.com
Who is filling out this form?
*
I'm filling out the form for myself
Someone else is filling out this form on behalf of the patient
Name of Person Filling Out Form
*
First Name
Last Name
Please Specify Relationship to Patient...
*
Tell us what you're looking for
I'm interested in...
*
Counseling/Psychotherapy (most people will select this option)
Counseling, Court-Ordered
Forensic Evaluation
Other
Type of Treatment...
*
Individual Counseling
Couples Counseling
Family Counseling
I'd like an appointment with...
*
First Available Therapist (either location)
First Available Therapist (Charlestown)
First Available Therapist (Canton)
Hyoseon Hardt, LCSW (Boston, Korean & English Language)
Kiriaki Kakoulidis, LMHC (Boston, Greek & English Language)
Kaitlyn White, LMHC (Boston)
Kaitlyn White, LMHC (Canton)
Diana Kane-Calvert, LMHC (Boston)
Richard Goggin, LICSW (Canton)
Richard Goggin, LICSW (Boston)
David Norrman, LMFT (Canton)
Jennifer Waczkowski, LMHC (Boston)
Lauren Demake, LICSW (Canton)
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
Out-of-Network Insurance
Insurance Provider
*
Insurance ID/Policy Number
*
Provider or Member Services Phone Number (usually on back of card)
*
-
Area Code
Phone Number
Submit Request
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