Bright Path Collaborative Counseling Send Message

Who would be receiving care?

Your info

Reason for care
You might share something about their personality, interests, strengths, sensitivities, and anything about who they are or how they experience the world that you would want me to understand from the beginning.
Limited to 600 characters
A few sentences are enough. You don't need to provide a complete history.
Limited to 600 characters
It's completely fine if you're not sure. Please share your best sense of what your child may be feeling, experiencing, or needing.
Limited to 600 characters
You might think about your child’s inner experience, your relationship with them, family patterns, your confidence as a parent, or what you hope may become more possible over time.
Limited to 600 characters
This might include suicidal thoughts, self-harm, serious aggression, behavior that could place your child or someone else at risk, significant property destruction, or any crisis or emergency support. If there are no relevant concerns, you may write “none.” This form is not monitored for urgent needs and should not be used to request crisis assistance.
Limited to 600 characters
Therapy appointments are typically scheduled for the same day and time each week. Please select every time range that could consistently work, rather than only your first choice. Selecting an option does not mean that an opening is currently available.
Limited to 600 characters
Limited to 600 characters

For medical emergencies, contact your healthcare provider or call 911. For mental health crises, call or text 988.

By submitting this form, you agree to the processing of your sensitive personal information, which may include protected health information (PHI). This information may be viewed by team members in this practice. You also agree not to submit any payment information, including credit or debit card details, through this form.