Contact

Client Date of Birth *

MM

DD

YYYY

Phone *

(###)

###

####

Are you currently seeing another mental health provider? *

Yes

No

If you would like to be seen in person, would you prefer our Hanover or Bedford location? *

Hanover

Bedford

Either

NA - I would only like virtual appointments

What state do you live in? *

New Hampshire

Vermont

Other

Please select: *

Insurance

I understand that you do not accept any insurance.

I am a Dartmouth student, and I would like to use my Dartmouth Student Health Plan.

I have Medicare, I understand you do not accept this insurance.

I have Medicaid, I understand you do not accept this insurance.

Please select all that apply:

I am interested in therapy services.

I am interested in a comprehensive educational assessment.

I am interested in both therapy and an educational assessment.