Appointment Request
To schedule an individual, child, couples, marriage, or family therapy appointment, or to obtain additional information about any of our services, please fill out the form below or give us a call.

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Client's Name: *
Today's Date *
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Referral Source
Client's Age: *
Name of Guardian (if Client is a Minor):
Contacts Phone Number: *

I consent to receive SMS text messages to the phone number provided for notifications and alerts from Psychotherapy Associates of Winchester (PAW), I understand that I am not required to provide my consent as a condition of purchasing any products or services. I understand I can opt out at any time by responding STOP. I can reply with HELP to get help. Message volumes vary.

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Privacy Policy and Terms and Conditions

Client's Insurance Provider (if applicable) *
**VALLEY HEALTH EMPLOYEES**   
If you are an employee of Valley Health please choose the correct plan.                                                                                     ______________________________________________________________________
**MEDICAID**   
Please note that PAW does not accept any Medicaid MCO                                                                                                         
Required
Insurance Eligibility Check

Please provide your insured member ID number:
Date of Birth for Insurance Verification
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Please choose all that are presenting problems or concerns *
Required
Preferred Therapist: (Please check all that apply)
If the chosen Clinician is not available and you are okay with another provider if necessary, Please choose the preferred provider and the Any Option.
Which Type of Appointment Would You Prefer? *
Your Email Address: *
What is Your Daytime Availability
Please Give a Brief Description of Your Concern:
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