Welcome to LiveWell Therapy Associates.

Thank you for inquiring about working with one of our therapists. We will respond to your inquiries, even if we don’t have current openings for new clients.

In order to help us assess if we can meet your clinical and scheduling needs, please take a few minutes to complete this form. This will give us some preliminary info about what you are looking for and see if that is compatible with what our practice can offer.

Please complete this form for the individual seeking treatment.

New Client Inquiry Form

Name

First Name

Last Name

Pronouns

Gender Identity

If comfortable, please include whatever words capture your gender identity

Date of Birth

YYYY

Phone

(###)

###

####

Physical Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

If using insurance, what is the name of your insurance and the specific plan name?

Livewell Therapy Associates is only in network with BCBS and Tufts.

Is there any secondary insurance plan (Medicare, 2nd policy through family etc)?

When are you able to be seen for sessions?

As a rule, the more flexible you can be, the more able we are to meet your scheduling requests.

Relationship Status

How were you referred to LiveWell?

If referred by another provider or physician, please indicate their name.

Have you been in outpatient psychotherapy before?

If so, when was the last time?

Are any current partners or family members currently in treatment at LiveWell?

What issues and concerns are you wanting to address in psychotherapy at this time?

What precipitating life or relationship event is prompting you to want to speak with a professional currently?

What therapist style or theoretical approach to therapy do you think you would respond best to? What approach do you think would not be helpful or a good fit for you?

Are you currently engaging in any self harming behaviors or thoughts?

Are you concerned about substance use/abuse or any other behavioral addictions?

Are you currently taking any psychotropic medication?

Is there anything else you would like us to know about you?