Intake Form
If you are seeking Suboxone services, please use the below link:
Based on our availability there may be a waiting period . Our facility provides medication management services for patients 18 years or older, and psychotherapy for patients 16 years or older.

**(PLEASE SUBMIT YOUR RESPONSES IN ALL CAPITAL LETTERS)**

Gender
Last Name
Your answer
First Name
Your answer
Date of birth
MM
/
DD
/
YYYY
Marital Status:
Race
Primary Phone Number
Your answer
Secondary phone
Your answer
Email
By supplying your email address, you are authorizing ICC to use your email address for communication including transmission of your personal and health related information.
Your answer
Address 1
Your answer
City / Town
Your answer
Zipcode
Your answer
Emergency contact name
Your answer
Emergency contact phone
Your answer
Emergency contact relationship
Your answer
Primary Care Doctor
Your answer
Please select the service(s) you are seeking
THIS FORM IS NOT FOR SUBOXONE PATIENTS. SEE BELOW LINK
Required
If you are seeking Suboxone services, please use the below link:
Diagnosis / Reason for visit
Required
Please check any medication(s) that you are currently or have recently been prescribed
Primary Insurance
Primary Insurance ID #
Your answer
Secondary Insurance
Your answer
Secondary Insurance ID #
Your answer
Are you available for last minute same day appointments?
Availability
Earliest
9AM-12PM
12PM-4PM
Latest
Anytime
Not available
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday (only AM available)
Have you been seen at Island Counseling Center before?
Required
Person completing this form:
Referred by:
Required
Additional Comments
Please indicate any additional information that would be helpful in scheduling an appointment
Your answer
For more information, please visit our website at www.iccworcester.com
Thank you for choosing Island Counseling Center
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