New Client Inquiry Form

Please take your time in filling out this form. Upon receipt, your form will be reviewed and if you are found to be a good match for our practice, you will be contacted shortly (usually within 48 hours).

First name

Last name

Email

Phone

What are you looking for help with? (situations, goals, symptoms).

Describe your current and previous psychiatric & medical history. (Include diagnoses, hospitalizations, and medications).

Describe your current and previous relationships with substances (including alcohol, marijuana, and any other drugs)

How do you currently cope with your challenges? What has been helpful, or not helpful, in the past?

Is there anything else you think we should know?

Andover Psychotherapy

New Client Inquiry Form