Clients Inquiry Form

Thank you for reaching out to Little Bridges Therapy.

This questionnaire will help to see if I have openings and can match your needs at this time. Please answer the questions based upon the person seeking care (ie. yourself or your child). I will contact you shortly for next steps. *Sometimes my replies end up in Spam - please be sure to check if you haven't heard back from us.

Name of the person seeking therapy

Date of birth and Age

Email address (of primary person to contact to arrange services)

Phone number (of primary person to contact to arrange services)

Guardians' names (If applicable)

Address (Including the city)

Permission to contact via email?

Yes

Permission to leave a voicemail?

Yes

Please share a little bit about what you are looking for in therapy.

What is your preferred language in order to receive services? (ie. English, Spanish, ASL, etc.)

If you need me to make any adaptations for your services to accommodate any disability or other need you may have please tell me what these should be.

Have you (or your child) experienced suicidal or homicidal thoughts, or been hospitalized for mental health in the past 6 months? If so, please describe.

Do you plan to use your health insurance?

Yes

Plan (e.g., Aetna, Kaiser, etc.)

Member ID

Primary insured name and date of birth

Therapy for a child or adolescent

Please describe the custody arrangement and parenting plan

I am married to my child's other legal guardian/parent.

I am divorced from my child's other legal guardian/parent.

I have never been married to my child's other legal guardian/parent.

I am the sole adoptive parent/guardian of my child

Child is in DHS custody

I am 15 years or older

None of the above describes your family situation. Please describe:

Please list any other information you'd like for me to know:

Your information will be encrypted.