New Client Inquiry Form

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Thank you for your interest in our practice. The purpose of this form is to provide preliminary information about our practice, and to gather information about the type of treatment you are looking for so that we can begin to identify who within our team might be a good match for you. In our practice we offer evidenced-based, targeted, short term treatment for OCD, depression, anxiety disorders, and PTSD. Our treatment modalities include CBT, ERP, DBT, PCIT, EMDR, DBT PE, and CPT. We look forward to working with you!

Email *

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Do NOT click on the "Request edit access" link on the bottom righthand corner of this page. Instead, simply click on the answer line below each question and type. Email info@mcg.works with any questions or difficulties with the form and we are happy to help!

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Please note that some of our therapists accept BCBS while others accept self pay only. Dr. Solodyna, Dr. Porter, Dr. Gerstel, Sam DiChiara, Shailee Vakulabharanam, Siggi Schorr, and Madeline Conover accept BCBS or self pay. Dr. Creedon, Betsy Harris, Deirdre Jiminez, Adam Gilman, Tim Lambertson, and Na'ama Malkesman accept self pay only. For clients who have out of network benefits, we provide monthly statements which can be submitted by the client to their insurance in order to receive partial reimbursement for services. We are accepting new clients. *

I understand and wish to move forward.

Required

Full Name of Person Seeking Treatment *

Preferred Name

Pronouns

Phone number *

Relationship of person completing this form to the person seeking services.

Name of Person Completing this Form (if different)

Email Address of Person Completing this Form (if different)

Phone number of Person Completing this Form (if different)

How did you hear about us?

McLean Hospital

BU CARD

Blue Cross Blue Shield Provider Search

Psychology Today

Friend/Family

Google Search

Current or Previous Client of MCG

Another Provider

School

IOCDF, ABC, or SPACE

Medical Provider

If you selected "Another Provider" above, please provide the name of the referring provider.

Are you inquiring for yourself or for someone else? *

Myself

My child (Please note that if your child is 18 or older we will need to speak with them directly.)

Another family member

A client

What is the age of the person seeking services? *

If the person to receive services is under 18 years old, are their parents divorced or separated?

Yes

If the person seeking services is under age 18, do all legal guardians consent to treatment?

Yes

Clear selection

How do you plan to pay for sessions? Please recall that some clinicians in our practice accept BCBS. These clinicians treat anxiety disorders in adults. The rest of our clinicians are self pay only. We do not accept any other insurances. *

I have BCBS HMO and am only interested in seeing a therapist who is in network with BCBS even if there is a longer wait.

I have BCBS PPO and am only interested in seeing a therapist who is in network with BCBS even if there is a longer wait.

I would like to do self-pay.

I have BCBS BUT am open to seeing a self-pay therapist if there is not a suitable BCBS provider available and/or the wait is shorter for a self-pay therapist.

Required

If the treatment recommended for me is DBT, I understand that it is self-pay only. There are no BCBS providers who provide DBT. *

Yes, I understand that no BCBS providers provide DBT and I will have to self-pay if DBT is the treatment recommended for me.

Required

What type of services is the person interested in? *

Individual Therapy

Group Therapy

Parent Coaching/Family Therapy

Clinical Supervision/Consultation (for professionals only)

Required

What modality is the person interested in? *

CBT/ERP

DBT

Trauma treatment (EMDR, CPT, PE, DBT PE, WET, MATCH)

PCIT

SPACE

DBT C

I am not sure what modality I want to try. I am open to what the therapist recommends.

Required

Please briefly describe what you would like help with in therapy at this time.

Also, if you have tried therapy before, please include a summary of treatments received including length and type of treatment.

Has the person being referred for therapy experienced any of the following in the past 6 months? Choose all that apply. ***Please note that if you or the person seeking treatment is currently feeling unsafe, you should call 911 or go to your nearest emergency room. This form should NOT be used to communicate a need for urgent or immediate care or response related to safety issues. *

Suicidal Thoughts

Suicide Attempt(s)

Self-harm

Substance Use

Running away

School avoidance

Psychosis

Trauma or significant loss

Problems with restricting eating, binge eating, or self-induced vomiting

Violence towards others

None of the above

Required

Has the person receiving services been hospitalized for mental health reasons? *

Yes, one time.

Yes, more than once.

Will the person interested in services be physically residing in Massachusetts at the time of services? *

Yes

Maybe

Is there anything else you'd like us to know?

What to Expect

Thank you for completing this form. We will be back in touch by email after reviewing your responses. We respond to inquiries via email within 1-3 business days. If you do not hear back from us, please check your SPAM folder or email us at info@mcg.works.

I understand what will happen next with regards to starting treatment at MCG. *

Yes

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