Intake Form
Email address *
If you are seeking Suboxone services, please use the below link:
IF YOU ARE INTERESTED IN TRANSCRANIAL MAGNETIC STIMULATION (TMS) PLEASE GO TO THE FOLLOWING LINK
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**(PLEASE SUBMIT YOUR RESPONSES IN ALL CAPITAL LETTERS)**
Gender *
Last Name *
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First Name *
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Date of birth *
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Marital Status: *
Race *
Primary Phone Number *
(PLEASE SPECIFY CELL, HOME OR WORK)
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Secondary Phone Number
(PLEASE SPECIFY CELL, HOME OR WORK)
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Address 1 *
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City / Town *
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Zipcode *
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Emergency contact name *
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Emergency contact phone *
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Emergency contact relationship
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Primary Care Doctor *
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Please select the service(s) you are seeking *
THIS FORM IS NOT FOR SUBOXONE PATIENTS. SEE BELOW LINK
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If you are seeking Suboxone services, please use the below link:
Diagnosis / Reason for visit *
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Please check any medication(s) that you are currently or have recently been prescribed
Are you currently being treated for by Mental Health or Substance abuse provider or program? *
If you answered yes to the previous question, please explain why you are seeking to transfer your services?
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Primary Insurance *
Primary Insurance ID # *
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Secondary Insurance
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Secondary Insurance ID #
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Are either of your insurance carriers a Medicare Advantage (also called Medicare Part C or Medicare Replacement plan)? Examples: Tufts Medicare Preferred, AARP Medicare, BCBS Medicare) *
Are you available for last minute same day appointments?
Availability *
Earliest
9AM-12PM
12PM-4PM
Latest
Anytime
Monday
Tuesday
Wednesday
Thursday
Friday
Have you been seen at Island Counseling Center before? *
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Person completing this form: *
Referred by: *
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Additional Comments
Please indicate any additional information that would be helpful in scheduling an appointment
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Please list the name, street and city of your preferred pharmacy? (e.g. CVS on Front St Worcester) *
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For more information, please visit our website at www.iccworcester.com
Thank you for choosing Island Counseling Center
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