Online Forms

Please Note: These forms are for patients who have spoke with the intake coordinator and scheduled an initial appointment.If you are interested in speaking with the intake coordinator please click here to fill out a contact request form. 


After you have booked your appointment, please fill the appropriate forms below.  The forms can be filled out and submitted online (you do not have to print them out). If you have any questions, please do not hesitate to reach out to us directly at 617.552.5116 extension 1

The Wellness Room Client Contract

(Fill this out if you are seeing a therapist or psychiatric nurse)

Insurance Script

(Fill this out if you intend to use health insurance)

Psychiatric Intake Form

(Fill this out if you are seeing a psychiatric nurse)

Adolescent Questionnaire

(Have your adolescent fill this out if they are seeing a therapist or psychiatric nurse)

Parent Questionnaire

(Fill this out if you have a child or adolescent seeing a therapist or psychiatric nurse)

Informed Consent for Telehealth Services

(Fill this out if you are interested in seeing a provider through an online portal)

Permission for Outpatient Mental Health Treatment

(Fill this out if you have a patient that is under the age of 18)

Release of Information 

(Fill this out if you wish to share information with an outside provider)

288 Walnut Street, Suite 220

Newton, MA 02460

phone: 617.552.5116

fax: 617.552.5117

    1 Ash Street, First Floor

    Hopkinton, MA 01748

    phone: 617. 552. 5116

    fax: 617.552.5117

    © 2019 by The Wellness Room