New Client Registration Form
PLEASE NOTE- We are not participating providers for MassHealth or Medicare or Unicare
Client's Information
Client's Full Name *
Please provide your full name as it appears on your health insurance card.
Your answer
Date of Birth *
Your answer
Address *
Street Name, CITY, STATE, ZIP
Your answer
Email Address *
Your answer
Primary Phone Number *
What is the best number for us to reach you at?
Your answer
Parent or Guardian's Information
If the client is under the age of 18, please complete the section below.
Parent or Guardian's Full Name
Your answer
Client's Relationship to You
Counseling Needs
Parent / guardian please reply on behalf of minor.
Have you received counseling services in the past? *
Services you are interested in *
Check all that apply
Required
What is your counseling need? *
What type of mental health support are you looking for?
Your answer
Do you currently have any significant medical issues?
Not required, but helpful if you can provide some information.
Your answer
When would you be available for counseling sessions? *
Please click as many as apply
Required
Location Your Are Requesting *
You can choose multiple. Clinicians vary by location.
Required
Insurance Information
WE ARE NOT PARTICIPATING PROVIDERS WITH: MassHealth, Network Health, Tricare, Medicare, or any Tufts PUBLIC plans
Client's Primary Insurance Carrier *
Client's Primary Insurance ID# *
Your answer
Insurance Subscriber's Name
If the client is also the primary insurance subscriber, please enter "self"
Your answer
Insurance Subscriber's Date of Birth
If the client is also the primary insurance subscriber, please enter "self"
Your answer
Client's Relationship to Insurance Subscriber *
Andover Counseling Clients?
If you are in treatment at Andover Counseling in North Andover, MA, please tell us your clinician's name.
Your answer
That's It !
PLEASE REVIEW OUR ON-LINE REGISTRATION PRIVACY STATEMENT: The information you send through this form will be stored safely and protected by data encryption and security protocols.

While very unlikely, internet communication has some risks. For example, completing this form on a public computer, or over an unsecured network, is not advised. If you prefer, you also may print this form (by clicking the file at the top of this page) and submit it via mail or fax.

By clicking submit, you have read and agree to our ON-LINE REGISTRATION PRIVACY STATEMENT.

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