Take the first step.

To make a referral please fill out the form on this page.

Client Name

First Name

Last Name

Client Date of Birth

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Client Email

Client Phone

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Client Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Insurance carrier

For example; Blue Cross, Aetna, Cigna, Optum Etc.

Insurance Member ID:

Primary Insurance holders name

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First Name

Last Name

Primary Insurance holders Date of Birth

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YYYY

Primary Insurance holders Email

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Primary Insurance holders Address

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Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Primary Insurance holders Member ID#

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If applicable, which provider are you interested in working with?

Take a look at our team page for provider info

Preferred times you can meet with your counselor

Mornings, afternoons, evenings, weekends, days of the week etc.

In-person or virtual preference

In-person

Virtual

Message

Presenting concerns, what brings you to therapy etc.

Are you experiencing a Crisis?

If you or a loved one is experiencing or suspect a mental health crisis or other emergency, please call 911, or your local emergency services program (aka Crisis Team), or go to your local Emergency Room.

Find your local MA Crisis Center by clicking Here