Welcome to Brighter Days!
Confidential Interest Form For Our Psychotherapy and Other Services

Brighter Days, Inc. exists to bring healing to the mind, body & spirit in one place. Please complete this form so we can better understand your concerns and assist you in obtaining your "brighter days". 
What is your name?   *
How did you hear about Brighter Days, Inc? *
Are you the identified client (or person seeking therapy)?   *
If you are not the identified client, what is your relation to the person seeking therapy? Note: Please complete the remaining questions for the person seeking therapy. 
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What is the date of birth of the person seeking therapy  *
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What is the home address of the person seeking therapy?  (Note: The psychotherapists are licensed in the states of Louisiana and Massachusetts, and they can not conduct sessions with individuals who reside or visit other states, per the state licensing board. If you reside in another state, we will refer you to www.psychologytoday.com to obtain a psychotherapist in the state of your residence).    *
What's your preferred telephone number?  
What's your preferred email address?  *
Briefly describe the reason(s) for psychotherapy and other wellness services (for example: depression,  anxiety,  trauma-related issues, coping concerns, self-care, health conditions, chronic pain, stress management, relaxation, psycho-education etc). *
Which services are you interested in? Check all that apply. 
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How will you pay for your therapy sessions?  *
If you answered Commercial or Supplement Insurance, which plan do you have?   *
For Psychotherapy, what is your preferred availability and type of appointment? Check all that apply. *
I understand that completing this form does not guarantee services at Brighter Days. I further understand if there is a waiting list, I may be offered group therapy sessions or referred to another therapist/program in the community. I also understand that a consultation will be scheduled prior to an intake assessment to determine the need for services or referrals in the community. Finally, I understand that I will not be considered a patient of Brighter Days until the consultation and intake packet are completed along with an intake appointment by one of our therapists. *
Thank you for completing this form. Do you have any general questions, or specific questions/concerns regarding any of the above questions? If so, please let us know. We are here to serve you. This Interest Form will be forwarded to one of our therapists or staff members who will follow up with you within the next 72 hours. Note: If you experiencing a mental health or medical crisis (for example: current suicidal or homicidal thoughts and/or need immediate medical assistance), please call 9-8-8 or 9-1-1, or go to your nearest emergency room.     *
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