Goals for Service Planning (Adult)
Clinician
*
Adrianne Smith
Aleksandra Weilogorski
Alice Rasmussen
Annette Szczesiul
Binnur Otay
Claire Duesler
Craig Gillespie
Dori Grasso
Ebony Rainge
Grace Thomas
Heather Bracken
Helly Parikh
Henry Torres
Jen Downing
Julia Contaxis
Julia MacLennan
Kaye Henry
Kiefer Rodriguez
Linda Haas
Louisa Tramontano
Melissa Lopes
Meredith Lall
Pamela Austin-Meizies
Patience Claver-Obinna
Rachel Gibson
Ruth Harrington
Sereina Colon
Stephanie Decembre
Stephanie Torres
Susan Rosenberger
Zachariah Saltzman
Please select the clinician from the card given to you by the front desk:
Client Name
*
First Name
Last Name
1. What are your reasons for coming to Bridges Healthcare, Inc.?
*
2. How have the above caused problems in your life?
*
3. Do you need help with other concern/problems or have any special needs or accommodations? (These may include assistance with walking, vision, hearing, and/or reading.)
*
4. What are your expectations for your child/family members during the assessment and initial treatment?
*
5. What do you hope to gain from coming to Bridges or being in therapy? How can we assist you in reaching your hopes, dreams, preferences, etc.?
*
6. How will you know when your goals are met (that is, when you would be ready to decrease your sessions or stop therapy altogether)?
*
7. Name of Primary Care Physician:
First Name
Last Name
Address of Primary Care Physician:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number of Primary Care Physician:
-
Area Code
Phone Number
8. Name of Emergency Contact:
*
First Name
Last Name
Relationship to you:
*
Phone Number of Emergency Contact:
*
-
Area Code
Phone Number
9. What times (day of week, morning, afternoon, evening) are you available for your appointments?
*
Signature:
*
Date
*
-
Month
-
Day
Year
Date
Submit
Should be Empty: