Bright Care Admin Inquiry

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

First/Last Name of Caller *

Relationship of Caller to the Client *

Self

Spouse

Parent/Guardian

Other:

First/Last name of client(s) *

Date of Birth *

Phone Number *

E-Mail *

Address *

In person or Virtual? *

In Person

Virtual

No Preference

Availability for Appointments (Check all that apply)

Morning any day and time between 8am - 12pm

Afternoon any day and time between 12pm - 6pm

Evening any day and time between 6pm - 8pm

I need specific days/times available (complete "other" option below)

Other (specific days/times needed):

Therapist: *

Best Time to Call *

Morning (Before Noon)

Afternoon

Evening (5-8pm)

Any Time

Payment Method *

Insurance

Standard Rate (Private Pay)

Sliding Scale

I'm willing to do self-pay or use insurance

Name of Insurance *

Member ID/Policy # *

Reason for seeking therapy *

How did you hear about us? *

Google

Psychology Today

Friend/Family Member

Other:

Submit

Clear form

Never submit passwords through Google Forms.

This form was created inside of Bright Care Christian Counseling.