Now Serving Communities in MetroWest Boston, Rhode Island, and Eastern Connecticut
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Tell us a bit about yourself, and when you're available for a visit.
Welcome to Braver!
If your family is already receiving treatment at Braver and want to enroll a new patient (such as another sibling or a parent), please add them to your family's account in the
Patient Portal
instead of filling out this form.
Patient Information
Patient First Name
*
Patient Last Name
*
Patient Date of Birth
*
MM
/
DD
/
YYYY
Patient Grade Level
*
Elementary School (K-5th grade)
Middle School (6-8th grade)
High School (9-12th grade)
Other
Sex Assigned at Birth
*
Male
Female
Patient Gender Identity
Man
Woman
Nonbinary
Transgender
Your Relationship to the Patient
*
I am the patient's mother
I am the patient's father
I am the patient's guardian
I am the patient
Email
*
Phone Number
*
I agree to receive text messages regarding appointment reminders and treatment information from Braver at the number I provided. Message and Data Rates may apply. Message frequency may vary. You can STOP messaging by sending STOP and get more help by sending HELP. Email
support@bebraver.com
for assistance. No mobile information will be shared with third parties/affiliates for marketing/promotional purposes. For more information view our
Terms of Service and Privacy Policy
.
Address
*
City
*
State
*
AL
AK
AZ
AR
CA
CO
CT
DE
DC
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
Zip
*
Availability
Tell us what days and times would work for this recurring weekly visit. The more times you are available the more quickly we can match you with a treatment team.
Monday
Morning (9am-12pm)
1:30-2:30pm
3-4pm
4:30-5:30pm
6-7pm
7:30-8:30pm
Tuesday
Morning (9am-12pm)
1:30-2:30pm
3-4pm
4:30-5:30pm
6-7pm
7:30-8:30pm
Wednesday
Morning (9am-12pm)
1:30-2:30pm
3-4pm
4:30-5:30pm
6-7pm
7:30-8:30pm
Thursday
Morning (9am-12pm)
1:30-2:30pm
3-4pm
4:30-5:30pm
6-7pm
7:30-8:30pm
Friday
Morning (9am-12pm)
1:30-2:30pm
3-4pm
4:30-5:30pm
6-7pm
7:30-8:30pm
Saturday
9-10am
10:30-11:30am
12-1pm
Afternoon (1pm-4pm)
Preferred Braver Office Location
Insurance Information
Name of Insurance Company
*
Member ID / Policy #
*
Insured's Relationship to Patient
*
Insured is the Patient's Parent
Insured is the Patient
Insured is the Patient's Spouse
Insured First Name
*
Insured Last Name
*
Insured Date of Birth
*
MM
/
DD
/
YYYY
Do you have secondary insurance?
*
Yes
No
Account Information
What are you seeking help for?
*
Has the patient ever received mental health treatment in an inpatient, partial hospital, or intensive outpatient program?
*
Yes
No
How did you learn about Braver?
*
Pediatrician
Friends & Family
Other healthcare provider
School
Online (web search, advertisement, etc.)
Health Insurer
Employer or workplace
Other
Submit
Ready to Participate?
Get in touch with us to discover if Braver's treatment program is right for you and your family.
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