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Wellness Within Appointment Request Form

Welcome to Wellness Within Collaborative where everything we do is because you matter. Fill out this form to request an appointment for yourself. We look forward to meeting you!

First Name*

Last Name*

Email*

Phone*

How may we contact you?*

Phone

Text

Email

All of the Above

Enter Your Date of Birth in this format: YYYY-MM-DD*

Gender Identity*

Preferred Pronouns

Sexual Orientation

Please describe choose your primary reason for seeking therapy *

Please briefly describe any additional details about what you are experiencing that we can help you overcome:*

We specialize in a Collaborative Healthcare approach for Whole Person Health. What would you like to learn more about for your individual Wellness Plan?

Yoga

Tai-Chi

Meditation/Mindfulness

Peer Wellness Groups

I'm Unsure

Our Collaborative Care Coordinator, Jordan, will be reaching out to you to discuss more information about additions to your Wellness Team after you establish care with your therapist. What's the best method to contact you?

Phone Call

Text

Email

Please Select Your Insurance Provider*

Insurance Member ID*

For Health New England - enter the last 2 digits of your Member ID :*

Please enter the mental health provider number from the back of your insurance card:

Secondary Insurance Provider (if applicable)

Secondary Insurance Member ID

Street Address (This is used to verify insurance eligibility.)*

City*

State*

Zip Code*

Due to COVID-19, we are still offering virtual sessions only. Are you open to teletherapy and what method is your preference? *

Phone Call

Video Call

Phone or Video Call

Not Open to Telehealth

Preferred Appt Time*

Preferred Appointment Days*

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

How did you hear about us?

Is there a specific practitioner you'd like to see at our Collaborative Healthcare group?