New Client Inquiry - Adults (18+)

If you are looking for therapy for a person under the age of 18 please use our New Client Inquiry Form for Children & Teens (Minors with Guardians)

All fields must be filled out in order to submit the form. If a question is not applicable then please fill in "N/A" .

Are you filling out this form for yourself or someone else? *

What is your name and your relationship to the client? Please elaborate on why the client cannot fill out the form for themself.

The primary email/phone number you enter is where you are going to get all of your communication. Please submit an email/phone number that will be checked often.

Primary Cell Phone *

Client Preferred Name

Birth Sex *

Sexual Orientation *

Relation to Client *

If the adult client has a legal guardian, please provide additional context below.

The Artful Life can accept the major insurances listed below:

Aetna
Allways / MGH
Blue Cross Blue Shield
Blue Cross Blue Shield Medicare Advantage
Blue Benefit
Fallon
Harvard Pilgrim
Health Plans, Inc.
Mass General Brigham (MGB)
Meritain Health
Tufts Commercial
Tufts Direct (Public)
Tufts Health Together (Public)
UMR
Unicare GIC
United Healthcare
WellSense
Private Pay

We are NOT able to bill Medicare, Medicaid, Masshealth, Steward Health, Tricare, Wellpoint & Cigna

What is your Primary Insurance Provider? *

Insurance Plan Name *

We are best able to understand your plan if you upload a photo of the front and back of your insurance card. *

I understand that The Artful Life does NOT bill out-of-network insurances. *

Do you have a secondary insurance provider? *

If so, who is your secondary insurance provider?

I understand that The Artful Life is unable to bill your secondary insurance. If you have secondary insurance, you will be responsible for paying any copays or deductibles that are normally covered by secondary. We can provide a superbill at your request which you can submit to your secondary insurance for possible reimbursement. Please reach out to your insurance representative with any questions regarding reimbursement

Why are you seeking counseling services at this time? *

What are you hoping to get out of counseling services? *

Have you ever worked with a therapist before? *

Please provide more information about your previous experience with therapy services:

Are you currently working with a therapist? *

Since you are currently working with a therapist, please provide us with an understanding of why you are seeking services at The Artful Life:

Have you ever received hospital-level care (inpatient, ER screening, partial hospitalization program, etc.) for your mental health? *

If YES, please add the month and year of when the hospital level of care occurred (to the closest date you can remember). *

How frequently have you experienced suicidal thoughts in the past 6 months? *

Do you take any psychiatric medications? If so, please list them below. *

Please select up to 3 primary issues below that apply *

Availability & Preferences

How Would You Like To Receive Services *

In-Person Only

Telehealth Only

Open to Both

* Please note that we almost always have daytime virtual sessions available. You are likely to be placed quickly by making this an option.

I am interested in daytime virtual sessions

I might be interested but I would like to be contacted with more information

I am interested but I don't currently have day time availability

I am not interested in virtual sessions

When are you able to attend sessions? Please be as flexible as you can, selecting as many options that you are available. *

Are there any times you are completely unavailable within the times you selected? (ex: required meetings, sports practice, etc.) *

Do you have a particular clinician in mind? *

For waitlist check-ins and updates how would you prefer to be contacted? *

Would you like to join our E-Newsletter? *

Yes

How Did You Find Out About Us? *

I Consent to receive SMS Notifications, Alerts & Occasional Marketing Communication from company. Message frequency varies. Message & data rates may apply. Text HELP to (978) 252-3417 for assistance. You can reply STOP to unsubscribe at any time. *

I understand that the use of email and SMS text messages are inherently insecure and thus poses a risk to the security and confidentiality of my protected health information and I consent to The Artful Life therapists and/or office staff communicating with me via email or text message