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Martha’s Vineyard Community Services
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Counseling Intake Form

Counseling services can be acquired by filling out the form below or by calling the bilingual intake line at 508-693-7900 ext 290. Portuguese-speaking clients may call Geany Rolanti at 508-693-7900 Ext 225 for assistance.

"*" indicates required fields

MM slash DD slash YYYY
Name*
MM slash DD slash YYYY
Billing Address*
Physical Address (if different than Billing)
Do you have a Legal Guardian?
Legal Guardian Name*
MM slash DD slash YYYY
Legal Guardian Address
Legal Guardian #2 (if applicable)
MM slash DD slash YYYY
Legal Guardian #2 Address
Special Communications/Needs:
Ethnicity:
Primary Payor/Insurance Information*
Policy Holder Name
MM slash DD slash YYYY
Policy Holder Address

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Services

  • Disability Services
    • Employment Services
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      • School to Employment Program
    • Support Services
      • Tools and Resources
  • Domestic and Sexual Violence Services
    • Community Education
    • Counseling: Crisis & Short-Term
    • Supervised Visitation
    • Survivor Advocacy
  • Mental Health Services
    • Counseling
      • Adult Counseling
      • Youth Counseling
    • Crisis Intervention
    • Health Forms
      • Counseling Intake Form
    • Mental Illness Rehabilitation
  • Peer Recovery Support Center
  • Senior Services
    • Outreach Services
      • CORE Referrals
  • Substance Use Disorder Services
    • Court Mandated Programs
    • Medication Assisted Treatment
    • New Paths Group Recovery Program
    • Recovery Coaching
  • Thrift Shop
    • Chicken Alley Thrift Shop Donations
    • Donate Furniture
      • Furniture Donation Form
    • Thrift Shop Volunteer Form
  • Transportation Access Program
  • Veterans Services
    • Discount Card
      • Merchant Enrollment
  • Youth and Family Services
    • Childcare
      • Childcare Center Application
      • Local Childcare Directory
    • Family Resource Center
      • Resources
      • Youth and Family Referrals
    • Head Start
      • Apply for Head Start
      • Parent Resources
    • MV Family Center
      • MV Family Center Referrals
      • Programs and Activities

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Martha's Vineyard Community Services enhances the lives of Islanders from every corner of the Vineyard community and in every season of their lives.

Contact Us

111 Edgartown Road
Vineyard Haven, MA 02568
508-693-7900
info@mvcommunityservices.org

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