New Client Inquiry - Children & Teens (Minors with Guardians)

Please Note: If you are seeking Therapy for multiple people in your family you will have to fill out a form for each individual person.

If the family member is 18 or older (even ones who live at home) or you are looking for therapy for yourself, please fill out our Adult Intake form.

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

Primary Contact Information:

The following section is for you to fill out about yourself so that we can contact you when we have a therapy match for the child.

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.

What is your name? *

What is your relationship to the youth that you are seeking therapy services for? *

Primary Cell Phone *

CLIENT (Child/Teen) INFORMATION

The following section is for you to give us information about your child who will be referred to as the "Client" in this section.

Client's First Name *

Client's Last Name *

Client's Preferred Name *

Client Age Range *

Birth Sex *

Sexual Orientation *

Relationship to Client *

Parent/Guardian 1 *

NAME
Relationship to Client
Phone
Email

Parent/Guardian 2

NAME
Relationship to Client
Phone
Email

Are the child's parents legally married? *

Do the child's parents/guardians share legal custody? *

If there is NO shared legal custody, please provide more information and context: *

If the parents are NOT MARRIED and share legal custody, you will need to provide the contact name and number for the other parent/guardian below. We are unable to contact you without this additional information. *

The Artful Life recognizes that there are clients whose families are involved in high conflict divorce and custody cases. Regardless of the custody agreement in place, our policy requires mutual consent from both parents. As an outpatient practice, we are not in a position to best serve clients who may need significantly more support and communication outside of standard session time. If you have a custody agreement in place, please provide any additional context that you feel may be important for us to know. *

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 for your child at this time? *

What are you hoping for your child to get out of counseling? *

Has your child ever seen a therapist before? *

Please provide more information about your child's previous experience with counseling services: *

Is your child currently working with a therapist? *

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

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

Does your child have a history of self-harm? (May include cutting, burning, scratching, etc.) *

How frequently has your child experienced suicidal thoughts in the past 6 months? *

Does your child take any psychiatric medications? If so, please list them below. *

Please select up to 3 primary issues below that apply to the child/teenager *

Who is the child's primary care provider? Please list the practitioner or organization name. *

What school does your child attend? If they are currently not in school, please elaborate on the situation. *

Availability & Preferences

What type of session format feels best? *Please note that we almost always have daytime virtual sessions available. Your child is likely to be placed quickly by making this an option. *

In-Person Only

Telehealth Only

Open to Both

When is your child able to attend sessions? Please be as *FLEXIBLE* as you can, selecting as many options they 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 the 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