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Services
Behavioral Health
Outpatient Services
Children's Behavioral Health Initiative (CBHI)
In-Home Therapy (IHT)
Intensive Care Coordination
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Addiction And Substance Program
Medication-Assisted Treatment (MAT)
Vivitrol Treatment
Intensive Outpatient Program
Partial Hospital Program(PHP) / SOAP
Drug And Alcohol Individual Therapy
Problem Gambling Therapy
Driver Alcohol Education
Recovery Coaching
The Second Offender Program
Residential Recovery Home
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Reason for Visit
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Addiction & Substance Use
Drug & Alcohol Education
Support & Stabilization Service (S&S)
In Home Therapy (IHT)
Structured Outpatient Addiction Program (SOAP)
Medication Management
Medication-Assisted Treatment (MAT)
Outpatient Service
Partial Hospitalization Program (PHP)
Therapeutic Mentor (TM)
Residential Recovery Home
Reasons for Visit may change based on the provider selected.
Patient Name
*
Birthday
*
Birth Sex
*
Birth Sex
Male
Female
Address
*
St
AA
AE
AK
AL
AP
AR
AS
AZ
CA
CO
CT
DC
DE
FL
FM
GA
GU
HI
IA
ID
IL
IN
KS
KY
LA
MA
ME
MD
MH
MI
MO
MN
MP
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
PR
PW
RI
SC
SD
TN
TX
UM
UT
VA
VI
VT
WA
WI
WV
WY
Phone
*
Email
*
Preferred Language
English
Abkhazian
Afar
Afrikaans
Akan
Albanian
Amharic
Arabic
Aragonese
Armenian
Assamese
Avaric
Avestan
Aymara
Azerbaijani
Bambara
Bashkir
Basque
Belarusian
Bengali
Bihari languages
Bislama
Bokmal, Norwegian
Bosnian
Breton
Bulgarian
Burmese
Catalan
Central Khmer
Chamorro
Chechen
Chichewa
Chinese
Church Slavic
Chuvash
Cornish
Corsican
Cree
Croatian
Czech
Danish
Divehi
Dutch
Dzongkha
Esperanto
Estonian
Ewe
Faroese
Fijian
Finnish
French
Fulah
Gaelic
Galician
Ganda
Georgian
German
Greek, Modern (1453-)
Guarani
Gujarati
Haitian
Hausa
Hebrew
Hindi
Hiri Motu
Hungarian
Icelandic
Ido
Igbo
Indonesian
Interlingua
Interlingue
Inuktitut
Inupiaq
Irish
Italian
Japanese
Kalaallisut
Kannada
Kanuri
Kashmiri
Kazakh
Kikuyu
Kinyarwanda
Kirghiz
Komi
Kongo
Korean
Kuanyama
Kurdish
Lao
Latin
Latvian
Limburgan
Lingala
Lithuanian
Luba-Katanga
Luxembourgish
Macedonian
Malagasy
Malay
Malayalam
Maltese
Manx
Maori
Marathi
Marshallese
Mongolian
Nauru
Navajo
Ndebele, North
Ndonga
Nepali
Northern Sami
Norwegian
Norwegian Nynorsk
Occitan (post 1500)
Ojibwa
Oriya
Oromo
Ossetian
Pali
Panjabi
Persian (Farsi)
Polish
Portuguese
Pushto
Quechua
Romanian
Romansh
Rundi
Russian
Samoan
Sango
Sanskrit
Sardinian
Serbian
Shona
Sichuan Yi
Sindhi
Sinhala
Slovak
Slovenian
Somali
Sotho, Southern
Spanish
Sundanese
Swahili
Swati
Swedish
Tagalog
Tahitian
Tajik
Tamil
Tatar
Telugu
Thai
Tibetan
Tigrinya
Tonga (Tonga Islands)
Tsonga
Tswana
Turkish
Turkmen
Twi
Uighur
Ukrainian
Urdu
Uzbek
Venda
Vietnamese
Volapuk
Walloon
Welsh
Western Frisian
Wolof
Xhosa
Yiddish
Yoruba
Zhuang
Zulu
Assyrian
Declined to Specify
Hmong
Sign Language
Other
Referring Provider/Entity
Primary Care Provider Name
Primary Insurance
*
Primary Insurance
BCBS
BOSTON MEDICAL CENTE
FALLON WELLFORCE
HARVARD PILGRIM
MBHP
MEDICAID
MEDICAID MANAGED CAR
SENIOR WHOLE HEALHT
TUFTS HEALHT PLAN
UNITED HEALTHCARE
None
Insurance ID
Upload Medical Record
Additional Insurance
(Secondary)
How did you hear about us?
Additional Details About
Reason for Visit
Back
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