Before you get started, please remember that all forms should be filled out at least 24 hours before your first appointment
BEFORE FILLING OUT FORMS
Here’s what to know before you get started
For Minor Patients: We require signatures from both parents or legal guardians, in ink. If there are custody agreements or legal documentation regarding decision-making, please provide these documents to move forward with the intake process.
HIPAA Release of Information: While the HIPAA Release Form is not required to start the intake process, it must be completed and submitted whenever there is a need to exchange information with other parties.
Insurance, if applicable: Please submit a front and back copy of your medical insurance card, as well as the card for your prescription benefits
INTAKE PACKET
Help us understand your history so
we can serve your needs
Mail: Mail forms to: 22 Stiles Rd, Suite 104. Salem, NH 03079
In-Person Drop-off: If you’re nearby, you can drop off your forms in-person. Please note our dedicated drop-off hours are Monday to Wednesday, from 9 am to 1 pm.
CONTACT US
We all have questions; let’s start the conversation
