New Client Submission Form: Nautilus Behavioral Health

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Thank you for your interest in our services. Please complete the form below to get started. Someone from our team will reach out to you to follow-up.

Email *

Parent's First and Last Name *

Child's First and Last Name *

Are you the child's parent or legal guardian? *

Yes

Are you legally able to make medical decisions and appointments for said child? Please keep in mind, we may request documentation. *

Yes

If you are requesting an appointment for a child, please confirm the following:
*

I have full custody and have court documentation

I share custody, have court documentation and the other parent agrees to therapy

Parents are partnered and agree to therapy

Not Applicable

Phone number
*

Date of birth:
*

YYYY

Please tell us a little bit about what you are looking for support with:
*

What state are you located in?
*

Which service are you interested in?
*

Individual Therapy

Family Therapy

Parent Training

Assessment (Learning Disability, ADHD, etc.)

Required

Please note that we do not provide the following:

Any Developmental Assessments (Delays, Autism, etc.)
ABA Therapy

Have you/your child had therapy services before? *

Yes

N/A

If you are seeking an assessment, have you have any assessments done before?

Yes

Clear selection

If so, please detail more below:

Tell us a little bit about what works best for you as far as a provider's interaction style (i.e. I'd I prefer to work with someone who is direct, offers feedback, is compassionate, nurturing, etc.) You can reference what you have liked or not liked about working with providers in the past if applicable:
*

If you are planning to use insurance for sessions, what type of insurance do you have? (Accepted insurance plans are listed below.)
*

Aetna

Tricare

Self-Pay

Other:

Please enter the Member ID from your insurance card (this allows us to verify benefits for services and is required in order to be added to waitlist):
*

Please enter the Group Number from your insurance card:
*

Is there a specific provider you are interested in working with? (Please note: not all of our clinicians currently have openings, however this information is helpful to us in understanding what you are looking for in a provider and we will work to offer you the closest match possible)*

Provider bios are available on our website: https://www.nautilusbehavioralhealth.com/meet-the-team.html

Are you or the person you are seeking services for experiencing any of the following:*

***IMPORTANT NOTE*** This form is not a substitute for crisis support. If you are feeling unsafe, or experiencing a psychiatric emergency, please call 988 or visit your local emergency room.

Current or recent thoughts of hurting yourself or someone else

Current or recent self harm behaviors

Current problems with substance abuse

Legal issues (divorce or legal custody arrangement, arrest history, DUI, DCF involvement, etc.)

None of the above

Required

If you endorsed any of the above, please describe here. If you checked "none of the above" simply write n/a here.
*

Please note that we do not provide court mandated services. We also do not provide services for ongoing legal or custody cases. *

I am not mandated for services by the court and I do not have any legal or custody cases.

Are there any specific scheduling needs we should consider when setting up your appointment time (i.e. mornings before 12pm, specific days of the week, etc.) ?
*

Thank you so much for this important information, as it helps us better determine the right match for you in working with one of our providers! We will reach out to you when we have an opening that meets your needs.

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