Secure Online Intake Form

Finding the most appropriate mental health clinician can be very difficult and confusing. Our staff will do everything possible to connect you with the most appropriate clinician for your needs. To make this process more efficient we ask that you complete a brief “intake” form below. Please complete the form and click on the submit button at the bottom of the form. Once we have received your request it will be reviewed by our staff and we will attempt to match you to an appropriate clinician. One of our staff will contact you by telephone or email, usually within 5-7 business days and inform you as to whether we can meet your needs.

You should get a confirmation that the form was submitted when completing the form. If you do not receive the confirmation or have any trouble submitting the form, then make sure to print and fax or mail the form per the directions on the form.

If you prefer to fax or mail the form, click here.

LuxSci helps ensure HIPAA-Compliance for email and web services.
Secure Internet Services

Fax or Mail Instructions

PDF-iconYou may opt to view this form, print it out and complete it. Then you may fax (781) 551-3396, or mail the form.

Questions? Call the main office at 781-551-0999 ext 501.