Consultation or Referral

Fill out this form if you would like to speak personally with a MIP member about a consultation or referral.

Please note that MIP is not an emergency service and it may take us a few days to respond. If you need immediate help, please call 1-800-985-5990 or text TalkWithUs to 66746 to connect with a trained crisis counselor.

Referral Form

Name(Required)

First Last

Email(Required)

Phone(Required)

Is location important for treatment, and if so, where is your preference?(Required)

Are you interested in meeting via telehealth?(Required)

Yes – telehealth only

No – in person only

I would like to have the option of both

Please tell us why psychoanalytic therapy is being sought at this time.(Required)

Do you have a preferred gender of your therapist or accessibility/language requirement?(Required)

How did you hear about MIP?(Required)

If you need to use your health insurance for treatment, please share your plan name and type (Blue Cross Blue Shield PPO, Tufts HMO, Aetna PPO, etc.). Please note that many MIP clinicians do not belong to panels, but offer out-of-network services, where you pay up front and seek reimbursement from your insurer. Insurance reimbursement is only possible if your plan is a "PPO" or "POS").(Required)

Providing your insurance information will enable us to help you find a better match (i.e., someone who takes your insurance).

Is there any additional information you would like to add to your request?

Captcha

Referral Form

Massachusetts Institute for Psychoanalysis

Join the MIP Email List