New Patient
Prescreening Form
Thank you for your interest in Kind Aligned Hearts! Please complete this brief form so we can learn about your needs and determine whether our services may be a good fit. We serve children, adolescents, and young adults ages 5 – 30.
A parent or legal guardian should complete this form for children under 18. Please keep responses brief and avoid including detailed medical records or sensitive identifying information.
What is the best way to reach you?*
May we leave a voicemail at this number?*
Does the prospective patient live in Massachusetts?*
What services are you seeking? Select all that apply*
Is the prospective patient currently working with a therapist or psychiatric prescriber?*
Has there been a recent psychiatric hospitalization, emergency mental health evaluation, or recommendation for a more intensive treatment program?*
Does the prospective patient currently use any of the following substances? Select all that apply.*
How do you plan to pay for services?*
Please do not submit insurance member numbers through this form. Insurance participation and benefits will be verified before scheduling.
What appointment format do you prefer?*
Do you need an interpreter or any accommodations to participate in care?*
If you or someone else is in immediate danger, call 911 or go to the nearest emergency department.