Colleen Fradette, LMHC, LCPC

Colleen Fradette, LMHC, LCPC Send Message

Who would be receiving care?

My partner and me

Someone else

Your info

First name

Last name

Phone

Name you go by

Date of birth

State

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Reason for care

What is the reason for seeking care?

Anxiety Behavioral issues Parenting or family concerns Depression Relationship issues Grief Attentional Difficulties Other

What mental health concerns or treatment have occurred in the past?

In therapy now In therapy in the past Taking psychiatric medication now Taken psychiatric medication in the past Hospitalized for mental health reasons now or recently Hospitalized for mental health reasons in the past Known neurologic or genetic disorder Attempted suicide in the past None of these apply

Administrative

Inquiry reason

How did you first hear about me?

Check all that apply — it helps me know what's working.

Google or another web search Psychology Today My insurance company's provider directory Referred by a doctor or another provider Referred by a friend, family member, or colleague Therapy Finder LinkedIn or social media Other

If someone referred you, who should I thank?

Optional — a name is helpful, but no need if you'd rather not say.

Billing & Payment

Payment method

How do you plan to pay?

Which insurance do you have?

If you're paying out of pocket, or aren't sure yet, you can leave this blank.

Blue Cross Blue Shield of Massachusetts Anthem Blue Cross Blue Shield (Maine) Harvard Pilgrim Health Care Optum / UnitedHealthcare Other — I'll bring my card to our call

Client Preferences

Preferred appointment times

Morning Afternoon Evening Weekend

Preferred modality

Is there anything that the practitioner needs to know?

For example: what you'd like to focus on, insurance or payment questions, etc.

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For medical emergencies, contact your healthcare provider or call 911. For mental health crises, call or text 988.

By submitting this form, you agree to the processing of your sensitive personal information, which may include protected health information (PHI). This information may be viewed by team members in this practice. You also agree not to submit any payment information, including credit or debit card details, through this form.