Welcome, 

This form is used to streamline counseling requests for new and returning clients. 

All information in this form is stored and protected using secure HIPAA compliant technology designed for healthcare. 

After submitting this form, I will reach out (usually via e-mail) to schedule a brief phone call to answer any questions you might have about our services and to provide additional information about the counseling process. You may have also requested that we check with your insurance to give you additional information about coverage and benefits, which can also be reviewed when we connect over the phone.  This information can be helpful for clients to have before moving forward with scheduling your first appointment.

By gathering information about your counseling and scheduling needs, we hope to help your family access services more quickly and find the best match possible. 

Be well, 

Elisabeth Thorpe, LCMHC

BrightMinds Counseling New Hampshire

Please note that only parents/guardians with legal decision-making may complete counseling referrals for their child or teen. In addition, if more than one individual shares legal decision-making, both coparents must both consent to counseling process before counseling may begin. 

For telehealth video appointments, parents/guardians should be available/at home throughout session time to help if there are technical problems or if clinical items need to be discussed.  This is especially important if there are any safety issues that emerge. A computer or tablet with camera + high speed internet is required for telehealth video. Finding a quiet, private location for the child or teen to complete their session is important. 

Scope of Practice 

Clinicians must operate within their scope of training and competence. Certain conditions  often benefit from specialized treatment. Please review the referral issues on home page to see if it seems to be a match for the current symptoms your child is facing before submitting your client inquiry form. If it does not seem to be a match, we encourage you to connect with your insurance provider to find local clinicians with specific training in these areas. 

Level of Care 
In addition, we are unable to provide urgent crisis appointments for safety assessment. Individuals struggling with acute suicidal ideation/behavior, violent behavior, psychosis, or safety risk behavior should be appropriately triaged to secure timely access to services. See local community mental health catchment areas at the bottom of this form  for local CMHC emergency services contact information. Community mental health centers may also offer intensive outpatient, in-home services, or crisis assessment. 

If you or someone you know is experiencing a mental health emergency, you may call emergency services, dial 911, or visit your local emergency room. If you are not in immediate danger however need to reach crisis services, you may also connect with the National Suicide Prevention Lifeline at 800-273-8255.