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Adult Inquiry Form

BrightMinds Counseling PLLC

HIPAA

Compliance

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    Welcome, 

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

    Please note that 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 you access services more quickly and find the best match possible. 

    Be well, 

    Elisabeth Thorpe, LCMHC

    BrightMinds Counseling New Hampshire

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    Telehealth video services cannot be provided across state lines unless the clinician is dually licensed in both states.
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    Please ensure that you leave a private number where we can leave a detailed voicemail
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    In person appointment availability is dependent on current Covid-19 risk level in the area. Computer or tablet with camera + high speed internet required for telehealth video. Anyone seen in person must be fully vaccinated and follow covid-19 policies (see website).  
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    Ex. Anxiety, depression, family stressors, grief, job change etc.
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    Ex. Prefer Fridays any time between 9-12pm (prefer in person, or telehealth) , Mondays after 3pm (in person, telehealth), M/Tu/Saturday mornings (telehealth), describe availability
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    Usually clients are given a weekly appointment time for a reoccurring appointment at the beginning of treatment. Many clients then chose to move to biweekly sessions as symptoms improve.
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    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 you are 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 immediate/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 below 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. 

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    If you are unsure of what your mental health coverage is for your current plan, it is highly recommended that you upload your insurance information before your intake appointment. It is always best to clarify with your insurance provider by calling the number on the back of your card under mental/behavioral health to fully understand your mental health benefits/coverage.
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    This information is only used provide to you the explanation of benefits (EOB) information from your insurance company. This may provide basic information to you about your current coverage, coinsurance, or deductible. No services are billed to your insurance prior to your first appointment. If you are not sure what your current coverage is, we highly recommend providing this information so that we can review this with you during your free consultation call.
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    This information is only used provide to you the explanation of benefits (EOB) information from your insurance company. This may supply basic information to you about your current coverage, coinsurance, or deductible. No services are billed to your insurance prior to your first appointment.
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    In some cases, a separate insurance entity may administer the mental health benefits of your plan which is separate from your medical health insurance carrier. This information is typically stated on the back of your insurance card. The back of your insurance card will also typically give the contact number for behavioral health benefits, which is very helpful for insurance verification. If you are not sure what your current coverage is, we highly recommend providing this information so that we can review this with you during your free consultation call.
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    Include any questions you may have about counseling services below.
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