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New England Center for OCD & Anxiety
Please fill out this form, and our intake coordinator will get back to you as soon as possible to schedule your free phone consultation to see if we can best support you or your loved one's needs.
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Which services were you seeking?
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General Outpatient Services (individual therapy with options for group/family services)
Intensive Outpatient Program - "IOP" (formal intensive outpatient services with 10-12 hours of treatment a week)
Unsure what is best option for person seeking services
Name (person seeking treatment)
*
Your answer
Name of person filling out this form (if different)
Your answer
Email
*
Your answer
Phone Number
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Your answer
Date of Birth (of person seeking treatment)
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Gender
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Male
Female
Non-binary
Prefer not to say
Other:
Home Address, City, & State
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Your answer
Why are you seeking out services?
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Your answer
How did you hear about New England Center for OCD and Anxiety?
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Your answer
Have you been given a diagnosis from a mental health professional?
If yes: what, by whom, and when?
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Your answer
As your primary insurance, do you receive Medicare, Medicaid, MassHealth, or another federally funded insurance?
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Yes
No
Office Location or Teletherapy Preference
(select all that apply)
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Melrose, MA
Cambridge, MA
Telehealth (MA)
Telehealth (NY)
Telehealth (CA)
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Do you have any specific questions about our programs?
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