The Counseling Center 
                                                       One Main Street * Nashua, NH 03064 * (603) 883-0005
                                                       8 Auburn 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
                                                      
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 Children & Teens

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 after additional clinical information is gathered 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 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)

calendar
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:

Would it be alright for us to leave a message at:
Would it be OK to text you for scheduling purposes? *
(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).
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 in 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 and account information to you via email? *
0/350 characters

Gender of Provider Requested, if possible: *
Have you left a message at our office yet or spoken with anyone personally in our intake department? *

Are you involved in a divorce process? *
Is the other biological parent in agreement for this appointment? *

If yes, is it hostile, contentious or involve any custody issues?
Are you and the other biological parent *

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/All That May Apply To Your Child

BEHAVIOR PROBLEMS
 
ACADEMIC PROBLEMS
 
PROBLEMS WITH FEELINGS
 
SOCIAL PROBLEMS
 
PHYSICAL COMPLAINTS
 
FAMILY PROBLEMS
 
DRUG/ALCOHOL ABUSE
 
PROBLEMS WITH THINKING
 

PLEASE COMPLETE BELOW

Have you or a family member been seen before at The Counseling Center? *



Has your child/teen seen a mental health provider before? *




Type of Provider: Psychologist or Counselor?
Psychiatrist or APRN for Medication?

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FOR ALL

Does your child/teen have any significant medical conditions? *


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Does your child have any handicapping conditions that require wheelchair access or other disability assistance? *

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

If yes, any experiences with a family member?

If yes, does your child/teen still have contact with that family member?

If Yes, any concerns about sexualized behavior of any type? *

Are there intense tantrums or behaviors you cannot manage? (If NO, skip next 3 questions) *
Do these involve destruction to property or aggression towards others? (If NO, skip next 2 questions)
Does this happen outside of the home?
If yes to any of the above questions, was there police involvement?

Has your child ever been to an ER or hospital for mental health or behavioral reasons? *
Ever received care at a Community Health Care Center? (If NO, skip next 2 questions) *

(if Yes) Was it case management
OR In-Home Services?

(If Yes) Did your child ever get help in a residential program or group home?

FOR TEENS

Please Check any Current Symptoms that May Also Apply In Addition to Those Identified Above:

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

Do you have a concern your teenager may have a substance abuse problem? *

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If the problem is alcohol, has your teen ever unsuccessfully tried to reduce or stop their drinking?

Has your teen's drinking ever impacted their health?

Any behaviors which result in self injury such as cutting, etc....? *

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Has your child/teen's self injury ever resulted in an ER visit?

Has your child/teen ever required a medical intervention such as stitches?

Has your child/teen ever had an inpatient stay for mental health? *


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Has your child/teen ever been in an outpatient/partial hospital program for mental health? *
ER visit for mental health? *
Any suicidal thoughts within the past year? *
Current suicidal thoughts? *

If yes, any suicidal plan/ideas or intent to act?
Prior suicide attempts? *

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Are there any repeated suspensions from school or issues with truancy? *
Is your child/teen currently involved in any legal matter or court litigations? *


if yes, are you looking for any documentation for your legal proceedings?

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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 and hit "submit" to send your appointment request.

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Do 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. If you are not aware of your deductible or out of pocket costs, please contact your insurance company prior to speaking to our intake coordinators to ease with the process of scheduling

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