Thank you for connecting with us. We will respond to you shortly. 11https://southernbridgecounseling.com/wp-content/plugins/nex-forms-express-wp-form-builderfalsemessagehttps://southernbridgecounseling.com/wp-admin/admin-ajax.phphttps://southernbridgecounseling.com/patientformyes1fadeInfadeOut *Name*Phone Number*EmailDate of BirthFull AddressGender--- Select ---MaleFemaleNon-BinaryPrefer not to say*Primary InsurancePut N/A if not applicable*Member IDPut N/A if not applicableGroup #Secondary InsuranceIf ApplicableHow did you hear about us? Back Next What type of therapy are you looking for? --Select-- --Select-- Individual Self Individual Self Couples Couples Child/Adolescent Child/Adolescent What led you to consider therapy today? --Select-- --Select-- I've been feeling Depressed I've been feeling Depressed My mood is interfering with my job/school performance My mood is interfering with my job/school performance I can't find purpose and meaning in my life I can't find purpose and meaning in my life I feel Anxious or Overwhelmed I feel Anxious or Overwhelmed I struggle with building or maintaining relationships I struggle with building or maintaining relationships I am grieving I am grieving I want to gain self confidence I want to gain self confidence I have experienced trauma I have experienced trauma Other Other Please write a short more detaled description about what is going onIf you have symptoms how would you describe them and when did they first appear? Back Next Do You Have a Preferred Clinician? Request are based on the clinician's availability.What is your prior mental health history?Any prior treatment? For what? When? Where?Previous mental health diagnosis?Prior hospitalizations? If yes; when and where? Back Next Do you have primary custody? --Select-- --Select-- Yes Yes No No If not who does?Explain if Other selected aboveAre you currently involved in legal proceedings, including custody disputes? if it is family matter tick appropriate box below.If not please click "Other" and write a short description of your problem. --Select-- --Select-- Where the children will live Where the children will live Time each parent spends with the children Time each parent spends with the children Child support/special experience Child support/special experience Spousal support Spousal support Taking the children out of province Taking the children out of province Decisions about the children Decisions about the children Threatening or violent behavior Threatening or violent behavior Enforcing or changing a court order Enforcing or changing a court order Financial issues (property, assets, debts) Financial issues (property, assets, debts) Other Other Back Submit Now Contact Us If you are experiencing a medical emergency, please dial 911 or go to your nearest emergency room. Please contact your insurance company if you have any specific insurance related questions. 478.449.1475