NEHS - Website - Spravato Screener Form

1
Do you have a diagnosis of depression?* This field is required.
YESNO
2
Spravato is a medication used to treat severe depression. Northeast Health Services can provide personalized mental health treatment that is right for you. Please complete our new client appointment form to get started.

New Client Appointment
3
Are you currently taking an antidepressant?* This field is required.
YESNO
4
Spravato might be an appropriate treatment for you, and your insurance may cover it. Next: Please submit your contact information and a member of our team will contact you to answer questions and confirm if Spravato is right for you.
5
Spravato is considered an "adjunct" medication, which is used alongside an anti-depressant medication. Insurance plans will require that you are currently taking an anti-depressant to qualify for Spravato. Are you interested in trying an anti-depressant for the purpose of pursuing Spravato treatment?* This field is required.
YESNO
6
Spravato might be an appropriate treatment for you. Please submit your contact information and a member of our team will contact you to answer questions and confirm if Spravato is right for you.
7
Northeast Health Services has many treatment options available for you including therapy and psychiatry. Please complete our new client appointment form to get started.

New Client Appointment
8
What insurance do you have?* This field is required.
9
Name* This field is required.
First Name
Last Name
10
Email* This field is required.
example@example.com
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Phone Number* This field is required.
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Date of Birth* This field is required.
Date
Year
Month
Day
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Did a medical professional recommend our services to you?* This field is required.
YESNO
14
Referring Organization Name* This field is required.
15
How did you hear about us?* This field is required.
Please Select
Please Select
Direct Mail / Flyer
Google / Internet Search
Health Insurance Directory
Returning Patient
Clinic Signage
Billboard
Social Media
Referred from Hospital
Referred from Primary Care Doctor / Pediatrician
Referred from Specialty Doctor (OB-GYN, Chiropractor, etc)
Referred from Psychiatrist
Referred from Therapist
Referred from Friend / Family Member
Referred from School
16
What is your nearest clinic?* This field is required.
Please Select
Please Select
Attleboro
Beverly
Boston Government Center
Braintree
Brockton
Chelsea
Danvers
Dedham
Fall River
Falmouth
Foxborough
Framingham
Hyannis
Haverhill
Lawrence
Lowell
Marlborough
Middleboro
Milford
Newton
Orleans
Pembroke
Plymouth
Quincy
Somerville
Sudbury
Taunton
West Springfield
Worcester
Woburn
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What is the best time to reach you?
8:00 am - 10:00 am
10:00 am - 12:00 pm
12:00 pm - 2:00 pm
2:00 pm - 4:00 pm
4:00 pm - 6:00 pm
6:00 pm - 8:00 pm
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Get Page URL
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