Contact

Intake Request Form

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I am

over age 18 and seeking care for myself
a parent or guardianactingon behalfof a minor

Name

First

Last

Sex and gender

Date of Birth

Phone Number

Single Line Text

Street Address

Street Address Line 2

City

Postal / Zip Code

State / Province

How do you plan to pay for services ?

Insurance
Private pay

If using insurance, enter your plan, and group number below

How did you find our practice?

Why are you seeking psychiatric care?

Are you having suicidal thoughts?

Have you ever been hospital for psychiatric reasons? if so, when and for what reason ?

Please list current medications and medical concerns:

Current psychiatric diagnoses:

What times and dates are you best available for appointments?

Any additional details you would like to share?

If you are currently experiencing suicidal thoughts or a life-threatening emergency, please contact 911, 988, or present to your nearest emergency room. You can also contact the Massachusetts Behavioral Health Helpline at 833-773-2445 or the New Hampshire Rapid Response Access Point at 833-710-6477, depending on the state you're in. Please note that this contact form is not monitored in real-time.

Experience our modern, personal approach to mental health.

It’s time to rewrite your personal narrative with intention and insight.

To schedule an intake, please contact us at the following:

Alex@Modern-Mentality.com

(781) 803-7757

95 Tremont Street Duxbury, MA 02332