New Client Inquiry - Gulf Coast Play Therapy Clinic, LLC

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THANK YOU for the inquiry!

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

Please Note: I am a small one clinician private practice with no administrative staff and I respond to new client requests myself around my current caseload schedule. This can cause a delay in responding, but I will always respond. Please be on the lookout for a return E-MAIL.

* I currently do not have any after school appointments available.
I would be happy to add you to a wait list if you require after school hours.
- Please note if you would like to be added to the wait list in the additional information section towards the bottom of this form and include days/times that may work best for your schedule.

E-Mail Address: *

Phone Number: *

Today's Date: *

YYYY

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 3-8? Please note: I only provide therapy services to children between these ages due to not currently offering traditional talk therapy. *

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 “additional information” section at the end of this inquiry.** *

Yes

There is a potential chance of litigation

Other:

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

Please note that I am only able to accept the insurances listed above. If I am unable to accept your child's insurance, would you like me to e-mail you with information for other therapists in our area who do?

Yes

Other

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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. Many children that are in sports or other extra-curricular activities must attend practice multiple times a week to be successful. We only ask for less than one hour one time 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 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

Required

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