The Counseling Center 
                                                            One Main Street * Nashua, NH 03064   (603) 883-0005                                    
                                                            148 Coolidge Avenue * Manchester, NH  03102 * (603) 627-3111
                                                            294 D.W. Highway * Merrimack, NH  03054 * (603) 883-0005
                                                            50 Nashua Road * Suite 305 * Londonderry, NH  03053 * (603) 432-3033
                                                           208 Robinson Road * Suite 204 * Hudson, NH  03051 * (603) 598-9958
                                                           45 Main Street * Peterborough, NH  03458 * (603) 924-3331
                                                           61 NH Route 27 * Unit 10 * Raymond, NH 03077 * (603)689-7602
                                                           
414 State Street * Unit 2 * Portsmouth, NH  03801 * (603) 334-2533
                                                           24 Front Street * Suite 304 * Exeter, NH 03833 * (603) 778-2005  
                                                           16 Lincoln Street * Suite C * Brunswick, ME 04011 * (207) 406-4222
                                                           319 Whittier Highway * Suite 8 * Center Harbor, NH 03326 * (603) 546-6178 
                                                                                          Fax all locations: 603-883-0007

First Time Appointment Request Form For Adult Referrals

If you would like to expedite the process of scheduling an appointment, please complete this form below for any one of the following office locations. If you do not hear back from us within 48 hours, please call (603) 689-7890 or email us at schedule@counselingcenter.com . We try to return appointments requests within a 24-48 hour time frame.

We provide this form to assist in speeding up the process of obtaining all the information we need to help schedule a first time appointment at The Counseling Center (if you are a returning client, please contact our office directly per the following instructions:  for psychologist or counselor appointments, please dial (603) 689-7900, and dial your provider's extension directly or option 2 for provider directory to reach him or her; for psychiatrist or psychiatric nurse practitioner appointments, please dial (603) 689-7977 for our front desk receptionist to request an appointment.
 
If you would like to proceed in completing this form below, the information below covers about 98% of all the information that we would otherwise ask you over the phone so it will save time later and help us schedule you more quickly if you choose to complete it now. However, if this is a clinical emergency, please do not complete this form but instead contact us at (603) 689-7890, and if you reach our voicemail box, please press option 3 to attempt to reach our intake department staff to assist you.  Please not that our ability to schedule a same day emergent appointment may be limited to those with specific insurance plans that contract with us to deliver this service, and is always on an appointment available basis.  These specific insurance plans providing coverage for emergency appointments include:  Harvard Pilgrim, Health Plans, United Healthcare, Cigna, Aetna, and Community Health Options.

NOTE ON PRIVACY: Your privacy and confidentiality is VERY important to us. This site is secure and meets criteria for HIPAA privacy.  You will notice in the lower right hand corner of this web page a "lock" indicating that the information cannot be viewed while you complete it, and after it is submitted it is encrypted during transmission, and is sent to our administrative office in Nashua and can only be accessed via secure passwords known only by our administrative staff who schedule appointments.  Your personal information will only be viewed by them and the provider you will be seeing.  All our staff are trained thoroughly regarding your privacy rights and maintaining confidentiality.  Despite this assurance, we understand that some people may not feel comfortable answering some items.  If you choose to omit items, those with an * do require an answer or the form cannot be submitted, so please just type in "omit" wherever possible and this information can be gathered later over the phone to assist with scheduling your first time appointment.
 
The more information you are able to provide for us, the easier it will be to schedule your appointment and match you with a  provider who has expertise to help you.

Assisting you in obtaining the right care from a provider with expertise that can help you is very important to us. On some occasions we find, based upon the information you provide us, that we will need one of our counselors or psychologists to speak with you to gather additional clinical information to help us match you with the correct provider, or to ensure that our practice can meet your clinical needs for type or level of care.  At times, we may find that we do not have a provider on staff who is a good match for the type of care you require, or we may determine that you would be best served by an alternate practice or facility specializing in the type or level of care you require.  If this is our determination, we will do our best to assist you by referring you to a local provider or community mental health center who offers the type of care or service needed to help you, and upon your written or email request and authorization, we could then forward a copy of this confidential information to you or to a provider at another practice of your choice to assist you in scheduling an appointment or receiving care. 

Items below marked with an asterisk (*) require an answer.  If a question does apply to you and it does not have an (*), please feel free to leave blank.  If the answer is required, but you choose not to answer it, please type "omit" or check at least one box.
~~ Please note regarding appointment availability: We are not currently accepting Medicaid plans, including Wellsense, NH Healthy Families, NH Healthy Kids, and Anthem Individual Marketplace Pathways plans. Please also note that in the month of April for psychologist or counseling appointments we have limited or no late afternoon or evening appointments due to extremely high counseling appointment demand, with the exception of those with Harvard Pilgrim, United Healthcare, Cigna, or Community Health Options plans, since all 70 of our providers participate with those health plans and therefore we have more scheduling flexibility.  For psychiatric medication related appointments, we currently have some afternoon and evening appointment openings, but no Saturday available appointments at this time.


Save & Return

Save your progress and complete this form later. (optional)

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What services are you requesting an appointment for? (check all that apply) *
 
What Office(s) Would You Like An Appointment At? (Check all that are options for You) *
 
Days of the Week You Are Available For Appts? *
Name of Person to Receive Care:

Is Secondary your Cell Phone? *
When is the best time to contact you? (check all that apply)
7 AM - 8 AM8 AM - 5 PM
YesNoYesNo
Home Phone
Mobile Phone
Work Phone
E-Mail
Text
Would it be alright for us to leave a message at:
(If yes to calling your mobile number, or your use a mobile number for a home phone, please add the following phone numbers to your contact list - 603.689.7890 & 603.881.9311).
Would it be OK to text you for scheduling purposes? *
If it is okay to text you, please add the following email address to your contact list to receive text messages from us - text messages will come from schedule@counselingcenter.com
We typically send out emails to confirm appointments, inform you of your benefits information, and/or to send you links to new patient paperwork. These emails are unencrypted, which means it could carry the risk of being read by a third party, but new clients often find this information helpful prior to their first appointment. Would you like to receive emails with information pertaining to your upcoming appointment and/or benefits? *
If the answer above is no and you do not want to receive items via email, please DO NOT provide your email address.
PLEASE NOTE: Email is not a secure medium and is not HIPAA compliant

Is it OK to email you about appt scheduling and send blank forms to complete via email? *
Is it OK to send future billing or account information to you via email? *

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Gender of Provider Requested, if possible: *

Have you left a message at our office yet or spoken with anyone personally in our intake department? *
Have you or a family member been seen before at The Counseling Center? *


Referral Source Information

Please let us know how you were referred to our practice
 
Were you specifically referred to one
 or more provider at our practice? *

Brief description of why you are seeking help at this time

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Please check any Current Symptoms that Apply:

Please mark any or all current symptoms that you or the person you are requesting an appointment for are experiencing:
 

PLEASE COMPLETE BELOW


Have you seen a mental health provider before? *





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Are you currently taking any psychiatric medications? *


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Have you ever taken psychiatric medications?


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Have you ever had an inpatient stay for mental health? *


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Have you had an inpatient stay for mental health more than one time? *


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Have you ever been in an outpatient/partial hospital program for mental health? *


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ER visit for mental health? *

Had any suicidal thoughts in your past? *

Have you ever had a specific plan? *
Seriously wanted to act on it? *

Any of these within the past year? *
Do you currently have:
Suicidal thoughts? *

If yes, any suicidal plan or intent to act?

Any prior suicide attempts? *


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Do you have any behaviors which result in self injury such as cutting, etc....? *


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Has your self injury ever resulted in an ER visit?


Have you ever required a medical intervention such as stitches?

Any experiences with physical abuse? *
Any experiences with sexual abuse? *


If yes, any experiences with a family member?


Do you still have contact with that family member?

Do you currently drink alcohol? *

IF YES
Within the last 5 years have you ever been concerned about your drinking or felt like you needed to cut down?
Have you ever unsuccessfully tried to reduce or stop your drinking?
Has your drinking ever impacted your health?
Has your doctor ever recommended that you cut down or discontinue your drinking?

Do you currently use marijuana or other drugs? *


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Have you ever been hospitalized for substance abuse or detox? *

More than once?
If you have received prior substance Use Treatment, please indicate the type:


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Do you have any chronic medical conditions? *


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Do you have any handicapping conditions that require wheelchair access or other disability assistance? *

Are you on any disability? *

If yes, do you require that paperwork be filled out for you by the provider?

If no, might you need any completed in the future?

Do you currently have mood swings that feel abnormal? *
Do you currently have:
Problems Sleeping? *
Problems overeating? *
Problems under-eating? *
Symptoms that persist more than one (1) day? *

Are you currently involved in any legal matter or court litigations? *

If yes, are you looking for any documentation for your legal proceedings?
Are you currently divorced, going through a divorce process or separated? *


If yes, is it hostile, contentious or involve any custody issues?


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INSURANCE INFORMATION: In order to match you with a provider who accepts your insurance and to fully complete our internal administrative process of arranging an appointment for you, please complete the following insurance information. If for reasons of privacy or concerns about providing your insurance identification number online despite the fact that this is a secure web page, please at least leave the name of your insurance company so we can appropriately determine who may be on your insurance panel to match your clinical need for an appointment. You may provide your identification number at a later date, after we are able to complete the scheduling of your first time appointment. . If you do not have insurance, or do not wish to use your insurance for purposes of confidentiality, please type in "self pay" in the first block and proceed to the end.


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Do you know if you have a deductible? * *
Has it been met?
* We gather this information to ensure we inform you prior to scheduling/prior to your first appointment the out of pocket cost of treatment.

Thank you for the time you spent to complete this form, as it will help us help you be matched with one of our 70+ providers who can best help you.  We pride ourselves on being able to respond to appointment requests within 24-48 hours, although occasionally our call volume prevents that. Our office hours are 8 a.m. to 5 p.m. If you do not receive a call within 48 hours, please call our office and leave your name and contact information, and be sure to leave the message that you completed on online appointment request form, and if available, the reference number you will receive after you submit this form.  You may also email us at schedule@counselingcenter.com if you do not hear from us.  Thank you.  Please hit SUBMIT below to send your request.

Evan Greenwald, Ph.D.
Director