Farmer Mental Health Support Program

Note: This form should not be used in the case of urgency or emergency. If this is an emergency, please contact 911, 988 or proceed to your nearest emergency room.

Please use this form to request an initial appointment. Your request will be directed to our Intake Coordinator. We will respond as soon as possible and within one to two business days.
If you do not hear back from us in that window of time, please contact our office at (603) 678-4751.

(* required info)

Clients First Name *

Clients Last Name *

Date of Birth * (mm-dd-yyyy)

Farm Name*

County*

Street Address*

City*

State*

Zip*

Phone *

(do not include 1- prefix)

OK to Leave Message *

Yes No

E-Mail Adr *

Your Preference *

I would like to access up to 10 sessions funded by this program.
OR I would like to use my insurance and have this program cover out-of-pocket expenses including deductible and co-pay up to a cap of $1,200. (please complete insurance information below)

Extension of services can be requested to be reviewed by our Clinical Director, dependent on available funds.
Please note: This support program is active through September 1, 2026.

Insurance Carrier

ID Number

Secondary Insurance

ID Number

Location Preference *

Telehealth New London Upper Valley Claremont Plymouth Keene Concord

Alternate Location Choice

Telehealth New London Upper Valley Claremont Plymouth Keene Concord

Does client have any have any current or historical concerns with substance use? *

Yes No

Does the client have any current or past concerns related to perinatal mental health (including pregnancy, postpartum, fertility treatment, or perinatal loss)? *

Yes No

Reason for Appointment *

If you were referred to Counseling Associates, who referred you?

Schedule Availability

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