Professional Referral Request an Appointment

Farmer Mental Health Support Program

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.

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.

(* required info)

Clients First Name *

Clients Last Name *

Date of Birth * (mm-dd-yyyy)

Farm Name*

County*

Street Address*

City*

State*

Zip*

Phone *

(do not include 1- prefix)

OK to Leave Message *

Yes No

E-Mail Adr *

Are you a farm business owner who materially participated in the business?

Yes No

Have you owned and operated your farm business for at least one season (including this current season)?

Yes No

My farm sells at least $1000 in products that we produce and we fill out Schedule F tax forms.

Yes No

Your Preference *

I would like to access up to 10 sessions funded by this program.
OR I would like to use my insurance and have this program cover out-of-pocket expenses including deductible and co-pay up to a cap of $1,200. (please complete insurance information below)

Insurance Carrier

ID Number

Secondary Insurance

ID Number

Location Preference *

Telehealth New London Upper Valley Claremont Plymouth

Alternate Location Choice

Telehealth New London Upper Valley Claremont Plymouth

Reason for Appointment *

Schedule Availability

Does client have any have any current or historical concerns with substance use? *

Yes No

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(603) 865-1321 NH / VT

(601) 699-4080 MS

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Counseling Associates of New London, Claremont, Hanover, Upper Valley, and Plymouth, NH : coming soon to Concord and Keene
Counseling Associates of Hattiesburg, MS

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