Request an Appointment

Please use this form to request an initial appointment. Your request will be directed to our Intake Coordinator. We will respond as soon as possible and within one to two business days.
If you do not hear back from us in that window of time, please contact our office at (603) 865-1321.
Please Note: This form should not be used in the case of urgency or emergency. If this is an emergency, please contact 911 or proceed to your nearest emergency room.

(* required info) 
Clients First Name *
Clients Last Name *
Date of Birth * (mm-dd-yyyy)
Street Address*
City, State & Zip*
Parents Name (if Client under 18)
(do not include 1- prefix)
OK to Leave Message * Yes No
E-Mail Adr
Insurance Carrier *
Secondary Insurance
ID Number
Location Preference
Due to COVID-19 precautions, we are currently providing the majority of services via secure telehealth. Please note your preferred location when in-person services resume or if you would like to continue via telehealth.
New London Upper Valley Claremont Newport Telehealth
Alternate Location Choice New London Upper Valley Claremont Newport Telehealth
Reason for Appointment *
Schedule Availability
Does client have any have any current or historical concerns with substance use? * Yes No
How did you hear about our practice? *
If you were referred to Counseling Associates, who referred you? *
 
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