New Client Inquiry
THANK YOU for the inquiry!
**I will be out of the office beginning February 20, 2020. I will return to the office on March 2, 2020 and will begin review of the received inquiries.**
* Required
E-Mail Address:
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Your answer
Phone Number:
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Your answer
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, I am unable to respond immediately, but will do so as soon as possible. **I will be out of the office beginning February 20, 2020. I will return to the office on March 2, 2020 and will begin review of the received inquiries.**
Name of Person Completing Form:
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Your answer
Name of Potential Client:
Your answer
Date of Birth of Potential Client:
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Is your child between the ages of 3-10? Please note: I only provide therapy services to children between these ages.
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Yes
No
Other:
If your child is not between the ages of 3-10, would you like me to e-mail you with information for other therapists in our area who work with children their age?
Yes
No
Other:
Very briefly, please describe your reason for seeking services for your child. If you prefer not to say, please indicate that.
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Your answer
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.**
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Yes
No
There is a potential chance of litigation
Other:
Child's Insurance Policy:
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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
No
Other:
I only offer services in Gulfport. Can you attend appointments at this location?
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Yes
No
Other:
Is there any additional information you would like for me to know?
Your answer
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