PCA Inquiry Match Questionnaire

Thank you in advance for your genuine and thoughtful responses.

Our heartfelt intention is to determine whether we can be of help and have the right clinical match for your unique needs, and to make useful recommendations for your care.

Once we’ve received your information, one of our Directors, who are all Clinical Psychologists, will carefully review what you’ve written and we will contact you today to discuss your needs in more detail.

If we receive your information after 3:30pm or over a weekend or holiday, we may not be able to get back to you until the next regular business day.

Five things to know before you begin:

  1. This form can only be completed in one sitting.  You cannot save and return to it at a later time.  So, please have all your information accessible, including your PCP and insurance information.
  2. We will only consider scheduling you with Doctors or Therapists who we judge to be good matches for your needs.
  3. Our Doctors and Therapists are highly sought after and so their time can be limited.  Your availability will be an important factor when it comes time to reviewing available appointments with Doctors or Therapists who are the right match for you.
  4. Because we know that looking for the right care can be a time-consuming and stressful process, if we determine that we don’t have what you need (taking into account the clinical, insurance and logistical information your provided), we will inform you promptly by email so as not to delay your search.
  5. We accept all insurance except Fallon, Tricare, and Mass Health (includes: BMC HealthNet, NHP, Minuteman).

Patient's:

    First Name (required)

    Initial

    Last Name (required)

    Suffix

Your Name (if different):

Patient is my:
 daughter son granddaughter grandson mother father wife husband other:

What Services are you possibly interested in? (Check off ALL that apply): Therapy Medication Testing Other:

Please tell us what you would like help with, including some background, how long or often you have struggled with this problem(s), and what you have tried to date.

Are you currently being treated for any medical, non-psychological/psychiatric conditions?  yes no

If Yes, what?

Who referred you to our practice or gave you our name? Office of your:

(required)

      Name or Practice:, Town:


Did anyone else refer you to our practice? Office of your:



      Name or Practice:, Town:

Primary Care Physicians (PCP) rely on our collaborative relationship for your good care.

PCPs Name: (required)

Practice Name:

City: State:

Patient's Age: Date of Birth: (required)

Sex: male female

Patient's Address: (required)

City State Zip (required)

E-Mail Address: (required)

Primary Telephone Number: (required)
Primary Number Type:  cell home work

Best times to call when you can talk - when you will be able to pick up the phone, as we must be able to reach you directly:

Secondary Telephone Number:
Secondary Number Type:  cell home work

Patient’s Primary Insurance Carrier (required):

Patient’s Primary Insurance I.D. #: (required)
Primary Insurance Tel #: (required)

Secondary Insurance I.D.#:
Secondary Insurance Tel #:

Insurance Subscriber's Name: (required)
Subscriber's Date of Birth: (required)

Relationship To Patient:
 mother father wife husband grandmother grandfather
 other

Subscriber's Employer:

Group #:

Appointment scheduling:

Please check off ALL appointment time windows you would be willing to consider for ONGOING appointments:

 before 2pm 2pm-4pm (These slots are always in immense demand, especially for pediatrics, and are often overbooked; we do not keep a waiting list) 4pm+ (These slots are always in immense demand and are often overbooked; we do not keep a waiting list) Additional specific scheduling requirements:


Please check off ALL of our office locations that you would be willing to consider for ongoing appointments:



Thank you for taking the time to share this information with us. Please take a moment to review what you have written to ensure you've told us everything that you think will be important for us to know. We will get back to you as soon as possible.

Note: The information you have provided on this form will be sent to us via email and once sent your information will not be retained or saved on this site. Information contained in email transmissions cannot be guaranteed secure and if this is of significant concern to you, you are certainly welcome to contact us by telephone at 781.646.0500 x126.

Please enter the code below and press the SUBMIT button to have this information emailed to us.

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