Now Serving Communities in MetroWest Boston, Rhode Island, and Eastern Connecticut
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Patient Portal
Patient Portal
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Tell us a bit about yourself, and when you're available for a visit.
Patient Information
Patient First Name
*
Patient Last Name
*
Patient Date of Birth
*
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
Intersex
Rather not answer
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
Preferred Braver Office Location
Billing
Insurance
Self-Pay
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
*
Insured Sex
*
Male
Female
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
Create Password
*
Confirm Password
*
Your password will be used to login to the patient portal.
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Get in touch with us to discover if Braver's treatment program is right for you and your family.
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