The Counseling Center
We're Here to Help
 

Help with Scheduling An Appointment

New Client Information Form

If you would like to expedite the process of scheduling an appointment, please complete this form below for any one of the following office locations. If you do not hear back from us within 24 hours, please call one of the numbers below.


Nashua 1 Main St., 603-883-0005, option 1
Merrimack, 294 D.W. Hwy, at Hitchcock Clinic, 603-883-0005, option 1
Hudson, 321 Derry Road at Hithcock Clinic, 603-883-0005, option 1
Manchester, 697 Union St., Phone:603-627-3111, option 1
Hampton, 234 Lafayette Road 603-436-0032, option 1

We provide this form to assist in speeding up the process of obtaining all the information we need to help you schedule a first time appointment at The Counseling Center (if you are a returning client, please call our office directly and wait for a return call rather than complete this form). If you would prefer the more personal option of talking with one of our intake specialists over the phone, you may call us at any of the local phone numbers above to reach someone, or if you have already done that and have left a message, someone will return your call as soon as is possible. If you would like to proceed in completing this form below, this covers about 95% of all the information that we would otherwise ask you over the phone so it will save time later and help us schedule you more quickly if you choose to complete it now. However, if this is a clinical emergency, please do not complete this form but instead contact our office and follow the prompts for emergency scheduling to determine if we can assist you on an emergent basis.

NOTE ON PRIVACY: Your privacy and confidentiality is VERY important to us. Because some of the information below is personal and confidential, we ask that you only put your first name and the first initial of your last name, and only one phone number for contact information. When we contact you, we will ask for your address and other demographic information to complete this form. Once this form is received in our office it is guarded by our confidentiality policies. If you feel that any information requested below is too personal or identifying to submit via an email form, you have the option of printing it and faxing it to us, or please feel free to omit that information and it can be gathered later when one of our intake specialists contacts you.

 

Have you left a message at our office asking for a callback?
 YES    NO
   
Have you been seen before at The Counseling Center?
 YES   NO
At what office location are you wanting an appointment? (Choose all that apply:
Nashua, 1 Main St.
Merrimack, 294 D.W. Hwy, at Hitchcock Clinic Office
Hudson, 321 Derry Rd, at Hitchcock Clinic Office
Manchester, 697 Union St.
Hampton, 234 Lafayette Road
 
    
Today's Date:
  
 
  
Your Name (First Name plus first Initial Last Name:
  
 
    
Gender:
   Male    Female
   
First Name and First Initial of Last Name of Person to receive care if different than yourself:
  
 
    
Age of Patient to receive care:
 
Parent or Guardian's Name(s) (if child) (First Name and First Initial of Last Name):
  
 
    
Contact Phone:
  
 
    
Is it okay to leave a message at the number above?:
   Yes    No
   
Email Address (please provide only if you authorize us to send you apt related information via non-secure email):
  
 
    
Is Is it okay to email you appointment related info only with the understanding that such emails are not secure in terms of HIPAA privacy requirements?:
   Yes    No
 
    
   
Day & Time appointment is requested (Please note that afternoon, evening and Saturday appointments are in high demand, so please provide some alternative options, if possible:
  1st Choice: Time:
  2st Choice: Time:
  3rd Choice: Time:
   
 
    
Gender of Provider Requested:
   Male    Female
   
Your Primary Care Doctor:
  
   
Primary Care Doctor's Address:
  
   
Primary Care Doctor's Phone Number:
  
   
Who referred you or how did you her about The Counseling Center?:
  
   
What life issues are you seeking help for? Please list or describe in detail so we can carefully match you with a provider who has the specific expertise to be of help to you:
  
   
Please indicate if you are looking for an appointment for talk therapy/counseling or psychological consultation with a psychologist/therapist or if you are seeking an appointment with a psychiatrist or advanced registered nurse practitioner for medication evaluation and monitoring only:
    
  Psychologist/Therapist (45 min. appointments) Yes    No
  Psychiatrist or ARNP (1st appt 45 mins, f/u appts 15-20 min.) Yes No
   
   
   
   
Below are additional questions about your clinical history to further ensure that we match you with the right provider, and make certain that we can provide you the highest quality care possible. If you are uncomfortable with any of these questions, please omit them and this information can be gathered later over the phone by one of our intake specialists.
   
Have you seen a psychologist, counselor, psychiatrist or psychiatric nurse practitioner before?:
   Psychologist/Therapist Yes    No (If Yes, date )
Psychiatrist                 Yes    No (If Yes, date )
Nurse Practitioner        Yes    No (If Yes, date )
   
If seen this calendar year, about how many visits have you used since January?:
  
   
If you are currently in care with another provider, please explain your reason for a switch:
    
No current provider 
             Reason for switch:
   
(For Children ages 12 and under please complete the 5 questions below and then skip to the insurance section below)
   
If child, are there any custody, divorce, or other legal issues pending between parents?:
   Yes    No
   
Any long-term (more than 3 days) school absences due to behavioral or mental health issues?:
   Yes    No If yes, date(s):
   
If current, do you require documentation to return to school?:
   Yes    No
   
Is your child taking, or has he or she been prescribed any medications for ADHD or other psychiatric conditions?:
  
   

***For Children 12 and under, please skip to the insurance section at the bottom:

For adults and teenagers ages 13 and over:
   
Are you being treated by a doctor for a medical condition?:
   Yes    No   (If Yes, for what: )
   
Have you (or your teen) used alcohol excessively?:
   Yes    No
If Yes, is current use excessive?:
   Yes    No
Was past use excessive?:
 Yes    No   (If Yes, when: )
 
Have you (or your teen) abused drugs or prescription medicine?:
   Yes    No   If Yes, is abuse current? Yes    No
   
Are you (or your teen ) bothered by past traumatic events in your life?:
   Yes    No
  If Yes:
Any current or past history of flashbacks or memories coming back to you about past events?:
   Yes    No
   
Any history of physical or sexual abuse or assault?:
   Yes    No
   
Any history of: Having thoughts of hurting or harming yourself?:
   Yes    No
  If Yes:
Ever acted on those thoughts?:
   Yes    No
   
If yes, any cutting?:
   Yes    No
   
If yes, any suicide attempts?:
   Yes    No
   
Any other way(s)?:
  
   
Ever been seen in emergency room for mental health issues? :
   Yes    No
   
Ever admitted to a hospital for Substance Abuse or Mental Health issues?
   
Substance Abuse:
   Yes    No   When:
  For:
   
Mental Health:
 Yes    No   When:
  For:
   
Currently on disability?:
   Yes    No
   
If yes, do you require disability paperwork completed?:
   Yes    No   NA
   
Any history of legal trouble?:
   Yes    No
   
Are you currently taking, or have you been prescribed psychiatric medications?:
   Yes    No
If Yes, List them:
1:
  
2:
3:
4:
   
For Adults and Teens: Please complete this section only if the person to receive care has visited an emergency room for mental health reasons, been hospitalized, or engaged in self harm behavior or threatened suicide. If not, skip to insurance section below. Please check the appropriate box for your answers below. If your answers for each time are sometimes yes and sometimes no, please decide if it is mostly yes or mostly no, and place a checkmark by that answer.
   
1. Do you try to avoid feeling rejected or left alone by others who you are close to?:
   Yes    No
   
2. Have you had any problems with relationships being filled with conflict, anger, and lots of ups and downs? :
   Yes    No
   
3. Do you generally have low self-esteem or feel you don't like yourself very much?:
   Yes    No
   
4. Have you had a tendency to engage in excessive spending, drinking, drugging, reckless driving, or binge eating? :
   Yes    No
   
5. Have you ever threatened suicide but not attempted it?:
   Yes    No
   
6. Have you ever attempted to harm yourself by cutting or some other way?:
   Yes    No
   
7. Have you ever attempted suicide?:
   Yes    No
   
8. Has your mood ever been really up or really down, and does it sometimes change quickly or frequently?:
   Yes    No
   
9. Do you generally feel empty inside?:
   Yes    No
   
10. Do you ever have trouble controlling your anger or temper?:
   Yes    No
   
11. Do you ever experience a sense of unreality or think that others might be out for you in some way?:
   Yes    No
   
INSURANCE INFORMATION
We accept most all insurance plans except Medicaid. Please complete this section only if you plan to use and bill your insurance company for services:
   
Your Insurance Company Name:
  
   
Phone # for Mental/Behavioral Health on the rear of insurance card:
  
   
Subscriber Name:
  
   
ID#:
  
   
Patient's relationship to subscriber:
  
   
Subscriber's employer :
  
 
Group # (if applicable):
  
   
Claims address from the rear of card for Mental/Behavioral Health:
  
 
    
Copayment for Behavioral Health, if indicated on card:
    
     
     
     
      


Thank you for the time you spent to complete this information. Please submit this form via the "submit" button above. We pride ourselves on being able to call you back within 2-6 hours. Occasionally, our call volume prevents that and it may be the next business day before we can get back to you. If you do not hear from us by noon of the next business day after you have called us, please call us again and leave a message that you submitted a form via the internet and are waiting for a return call, and please remind us of when you placed your first call to our office, and leave your first name, first letter of your last name, and contact phone number you provided above so we can match your call to this form. Thank you.

Evan Greenwald, Ph.D.
Director
The Counseling Center
One Main Street
Nashua, NH 03064

Phone: (603) 883-0005 Ext. 306
E-Mail Intake Department
 
 

© Copyright The Counseling Center 2003. All rights reserved.