Bridge To Restoration Therapy Services

1
Client's Name (upload Identification card)
First Name
Last Name
2
Client's Date of Birth
Date
Month
Day
Year
3
Relationship to client:
Please Select
Please Select
Self
Parent
Guardian
Spouse
Other
4
Contact Email
example@example.com
5
Phone Number
Please enter a valid phone number.
6
Insurance Carrier (Upload front & back of card)
7
Front of card
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
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8
Back of card
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
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9
Insurance ID number
10
Identification card
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
11
Primary Person Insured Name & DOB
12
Briefly explain why you are seeking therapy:
13
HospitalizationsPlease list any hospitalizations in the past 90 days with dates
Huge
Large
Normal
Small
Ok
Ok
14
Suicidal Ideation
YESNO
15
Virtual or In-Person
Please Select
Please Select
Virtual
In Person
16
Specific day or time for sessions:
17
Specific Therapist:
Please Select
Please Select
Hasina Bankston, LMSW
Dr. Patricia Keller, PhD
Dr. Tracy Newbern, PhD
Meghan Beeks-Davis, LMSW
Vivian Keller, LMSW
Dwayne Johnson, LLMSW
Crystal Barnett, LLMSW
18
How did you hear about us?
Please Select
Please Select
PsychologyToday
Our Mental Health Collective Grand Rapids/Mental Health Clinicians of Color
Word of Mouth
EAP/Insurance
Google
Instagram
Facebook/Meta
19
Referred By
20
What is the best way to contact you?
Phone
Text
Email
21
Question/Concerns:
Should be Empty: