Resilient Care Therapy LLC

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If you are interested in the counseling service with RCT, please fill out the form.

Referrer's role/title or relationship with client *

Referrer's name (First, Last) *

Organization

Referrer's email *

Referrer's phone number (extension, if applicable) *

Reason for referral *

Patient first name *

Patient last name *

If the patient is a minor, please enter the name of a guardian. (First name, Last name)

Patient's Date of Birth *

YYYY

Gender *

Cisgender Woman (A woman who was assigned female at birth)

Cisgender Man (A man who was assigned male at birth)

Transgender Woman (A woman who was assigned male at birth)

Transgender Man (A man who was assigned female at birth)

Non-binary (A person whose gender identity is neither entirely male nor entirely female)

Other:

Phone Number

(If the patient is a minor, please provide the phone number of one of the guardians)

Email *

Insurance *

Aetna

Aetna Student Health Insurance

Berklee College of Music Student Health Insurance

Boston College Student Health Insurance

Blue Cross Blue Shield

Carelon

Cigna

Florida Blue

Harvard Pilgrim

Harvard Student Health Insurance

Independence Blue Cross

Lesley University Student Health Insurance

Mass General Brigham

MIT Student and Affiliate Extended Insurance Plan

Northeastern University Student Health Insurance

Optum

Oscar Health

Oxford Health Plans

UMR

United Healthcare

Self-pay/ Private pay

Other:

Interested Counseling Type *

Individual Counseling

Couples Counseling

Family Counseling

Business Consultation

Career Counseling

Unknown

Other:

Required

Therapist Preference

Do you have a preference of whether your therapist is older or younger, specializes in a specific area of expertise, or anything else?

When do you want to start therapy? *

YYYY

What is your preferred session time? *

Weekday daytime

Weekday evening

Weekend daytime

Weekend evening

Open to any time

Required

What is your preferred method of contact? *

Phone

Is there anything else you would like to share?

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