The Counseling Center of New England

One Main Street * Nashua, NH 03064 * (603) 883-0005
8 Auburn Street * Nashua, NH 03064 * (603) 883-0005
15 Trafalgar Square * Nashua, NH 03063 * (603) 883-0005
148 Coolidge Avenue * Manchester, NH  03102 * (603) 627-3111
294 D.W. Highway * Merrimack, NH  03054 * (603) 883-0005
77 Gilcreast Rd * Suite 3000 * Londonderry, NH  03053 * (603) 432-3033
45 Main Street * Peterborough, NH  03458 * (603) 924-3331
414 State Street * Unit 2 * Portsmouth, NH  03801 * (603) 334-2533
24 Front Street * Suite 100 * Exeter, NH 03833 * (603) 778-2005  
16 Lincoln Street * Suite C * Brunswick, ME 04011 * (207) 406-4222
53 Baxter Boulevard * Portland, ME 04103 * (603) 883-0005
61 NH Route 27, Unit 10 * Raymond, NH 03077 * (603) 689-7602
319 Whittier Highway * Suite 8 * Center Harbor, NH 03326 * (603) 546-6178 
Fax all locations: 603-883-0007

FIRST TIME APPOINTMENT REQUEST FORM (CHILD & TEEN)


~~ 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.
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.

Save & Return

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

** Please create your account or log in prior to starting your form. If you leave form to create your account, you will lose any data you have completed prior to that point. After account created and the form partially completed, make sure to click "SaveProgress" at the bottom of the form.
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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:

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).
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 and 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? *

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 receive treatment 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 self-injurious behaviors? *

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Has your child/teen's self injurious behavior ever required medical intervention?

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 school refusal? *
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