Let’s connect

Hello, welcome to MCC. We are here for you.

Please fill out this confidential form and an administrator will contact you.

You may also call us at 781-631-8273 (Mon-Fri 8:30 am – 5:00 pm).

Please note: We have a higher than normal wait time for appointments and we may not be able to respond immediately. We thank you for your patience.

If this is an emergency, call 911, your primary care doctor, or go to your local emergency room.

781-631-8273
Office Hours: 8:30 am - 5:00 pm
Clinical Hours: 8:30 am - 5:00 pm

info@marbleheadcounseling.org

66 Clifton Avenue Marblehead, MA, 01945 United States
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Mental Health Intake Form

"*" indicates required fields

Client Name:*

Full Name*

Gender*

Caller (if other than client):

Full Name*

Relationship to Prospective Client*

Self

Mother

Father

Guardian

Address:*

Address Line 1*

Address Line 2

City*

State*

Zip Code*

Client Birthdate*

Birthdate*

Preferred Communication:*

Preferred Communication*

Phone

Phone*

Alternate Phone

May Leave Voicemail*

Yes

Email Address*

Preferred Appointment Days and Time?*

Situation*

Please share your challenge to help us expedite your placement.

Insurance*

Insurance ID

Secondary Insurance (if applicable)