New Client Inquiry - Gulf Coast Play Therapy Clinic, LLC

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THANK YOU for the inquiry!

Here is some information about the clinic:

- I specialize in play therapy with children between the ages of 3 to 8 years old.

- I am only a provider for the following insurances: BCBS, SAS, First Choice, and Mississippi Physicians Care Network

- THERE IS A WAITLIST FOR NEW CLIENTS! Once established as a client, you can then be added to an after school slot once it opens up. I do offer school and work excuses!

If you are looking to get in with someone sooner, Jasmine Smith is another therapist trained in play therapy with more openings currently. She owns Stepping Stones Counseling, LLC and is currently sharing office space with Gulf Coast Play Therapy Clinic, LLC. Jasmine can be reached at steppingstoneslpc@gmail.com or 228-338-6769. She is on panel with multiple insurance companies.

- **I do not have any administrative staff in the office** I am a small one clinician private practice and I respond to new client requests myself around my current caseload schedule. This can cause a delay in responding, but I will reach back out as soon as I am able. Sometimes e-mails go to spam, so check there also!

Please be sure to view my website: https://www.gcplaytherapy.com/
for additional information about play therapy and the clinic.

Once you hit submit, this form will automatically notify me.

THANK YOU!!

PLEASE MARK BELOW TO INDICATE YOU HAVE READ THE INTRODUCTORY INFORMATION.

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E-Mail Address: *

Phone Number: *

Today's Date: *

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Please fill out this short form and Infanta will get in contact with you. Please note that due to daily client appointments, there is normally a delay in responding, but please be on the lookout for an e-mail or a voicemail. If you or your child is a danger to self or others or has a life threatening emergency, please contact 911. I am unable to provide crisis support services and this form is not monitored on a 24 hour basis.

Name of Person Completing Form: *

Name of Potential Client:

Date of Birth of Potential Client: *

YYYY

Did anyone refer you to our clinic? If so, who?

Is your child between the ages of 3-9?

Please note: I only provide therapy services to children between these ages due to not currently offering traditional talk therapy. Please let me know if your child is over the age of 9 but may still be interested in a playroom.

Yes

Other:

Very briefly, please describe your reason for seeking services for your child. If you prefer not to say, please indicate that. *

Do you currently have a court or custody case open that involves or could potentially involve your child in any way? **I am currently unable to provide treatment to anyone actively involved in divorce or custody proceedings. The court case must be settled. I would be happy to provide you with contact information of someone better suited for your needs. Please indicate if you would like this information in the “other” section below.** *

Yes

There is a potential chance of litigation

Other:

If parents are separated / divorced / divorcing, I do ask that both parents be invited to the intake and sign consent paperwork Unless there is some special circumstance that has occurred as to why this cannot or should not happen.

Yes, we can do this

No, we cannot do this

I need to discuss this with you

N/A

CHILD'S Insurance Policy (I am only able to accept the insurances listed below): *

Blue Cross Blue Shield (BCBS)

Advanced Health Systems (AHS)

SAS (Select Administrative Services) / First Choice

First Choice (Other)

Mississippi Physician's Care Network (MPCN)

Other:

Required

Is there any additional information you would like for me to know?

It is essential to keep in mind that therapy is not a magic pill or a quick fix: therapy is a healing process that necessitates participation and investment. Play therapy is a commitment and requires consistency as much as possible. Children feel safest when the adults around them create predictability by establishing set routines and consistency within their days. This isn’t always possible, but when we’re able to, we want to try to. We try really hard for play therapy to happen at the same time every week, in the same place, and with the same therapist, in order to provide consistency for the child and to help develop trust in their therapist that they will not let them (the child) down. Another way we like to look at it is even if we meet once a week for a year, that’s barely over 1 work week of therapy we’re getting in the year. And twice a month is even less than that. Many children that are in sports or other extra-curricular activities must attend practice multiple days a week, for hours each practice to be successful. We only ask for less than one hour one day a week (appointments run about 45-55 minutes one day a week). With understanding that play therapy is a process, it is also important to note that while results are important and anticipated, your child’s growth can’t be hurried or pushed along. Some children demonstrate change quickly and others take a little longer, making it difficult to predict how many sessions a child will need. Please also remember, we’re not looking for perfection – we’re looking for improvement.

I understand the above statement

I Do Not understand the above statement

I would like to discuss the above statment with you

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