Resonance Mental Health Pre-Screener

This form is personally reviewed by Brianna Boulanger, PMHNP-BC in order to explore whether the requested relationship would be a good fit. Filling out this form is not a guarantee of services nor do we have a waitlist.

If you are or believe you are experiencing a medical or psychiatric emergency, including suicidal or homicidal thinking, side effects to medication, or any other urgent or time-sensitive matter in which you need an immediate response, do not use this service. Instead call 911 or go to your closest emergency room.

Once this form is submitted, the front desk will contact you within 2-3 business days to notify you of the decision. We are closed on Fridays and weekends. If you do not hear from us and would like to check in, please give the office a call at 603-473-4451 to follow up. We will only reach out to you if you are accepted.

Our office tends to schedule intakes 1-2 months in advance. No urgent intake slots are available. We treat ages 18-64. 

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E-Mail-Adresse *
What is your full name? *
What do you like to be called? *
What is your date of birth? *
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What is your current mailing address?
 *
What is your phone number? *
What is your preferred email? (This will be connected to your patient portal account if you are accepted) *
What are you seeking assistance with? *

Do you suspect or have you been told you might have OCD, PTSD, Depression, or Anxiety? (These are Bri's specialties, but she does treat other diagnoses)
 *
What medications are you currently on? *
Do you have a therapist? (We do not have therapists here, but highly recommend one in conjunction with medications. Answering no will not cause a rejection.) *
Who referred you to us? Please write self if self-referred. *
Have you been psychiatrically hospitalized in the past 6 months?
 *
Have you attempted suicide in the past 6 months?
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Do you have any genetic or developmental disorders? (Per Example: Down Syndrome, Cystic Fibrosis, Fragile X, or Developmental Delays)
 *
Do you agree to come to the office IN PERSON for your first appointment? You may switch to telehealth after.
 *
Please list your insurance company or planned method of payment. *
If there is anything else you would like to share with the practice, please add it here.
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