Patient Contact information and Referral Form

Please complete the following questions to the extent to which you feel comfortable.   Please know that email communication via our website may not be done through a secure platform. Although it is unlikely, there is a possibility that information you include in your submission can be intercepted and read by parties other than the intended recipient. To protect your confidential information, please do not include personal identifying information such as your full birth date or personal medical information in any emails or website submissions you send to us.

Once received, we will be in contact to schedule with you.  Thank you so much and we look forward to connecting with you.
Email *
Client Name (First Name, Last Initial only) *
Are you at least 18 years old? (We only treat adults) *
Complete Address of Client: *
Phone number to best reach client to schedule: *
We offer a 15 minute phone consultation, free of charge, if you want to make sure our practice and approach is right for you.  This consult is free, and would take place prior to an intake appointment.  Is this something you are interested in?
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General reason you are pursuing counseling? (this answer is not required.  Please only share to your extent of comfortability. )
We accept BC/BS of Massachusetts, United, Tufts Commercial Health Plan, and private pay for services.  Which method of payment do you plan on using?  If using insurance, Please include Health Plan Name, ID # and Group #  from your health insurance card below.   *
Insurance Subscriber Name, Relation to Client, and their Date of Birth: *
Finally, How did you hear about Meghan Gerardi and/or Retreat Wellness Group?
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