Thank you for reaching out to us! Please fill out this form and our Care Coordinator will contact you if we have availability. We are often booked, so we recommend checking out psychologytoday.com and therapyden.com for more recommendations. If you are in crisis, call 211, or for immediate help, call 911 or go to your local emergency room. Main number: 860-281-1133
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First and Last Name (Of the client) *
Name of parent or guardian (Skip this if client is an adult)
Birthday *
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Telephone number (123-456-7890) *
Email address *
How would you like to be contacted?
Please provide some details about what you're seeking in therapy - maybe 2 or 3 of your top reasons. This will help us match you with a therapist.  *
Preferred office (Check all that apply) *
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What is your availability? (Check all that apply) *
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Preferred therapist (Check all that apply)
Have you been hospitalized due to mental health in the past year? If yes, please provide a few details.
Insurance company (Check all that apply) *
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What is your insurance member ID number? (Type N/A if you have no insurance or do not have an ID number yet.) *
Are you currently seeing another mental health provider? If yes, please choose other and list name and contact information.
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Are you currently involved in a legal case (criminal, workers' compensation, disability, accident/injury, DCF)? If so, please choose other and provide details. *
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