Goals for Service Planning (Youth)
Clinician
*
Adrianne Smith
Aislynn Kostandini
Ali Depaul
Allison Driscoll
Alyssa Miralles
Amy Burrell
Anthony Richardson
Ashley Ness
Audra Etes
Berthania Boursiquot
Breanna Sansone
Carlie Dackson
Christina Moore
Daniel Resto
Danielle Casapulla
Deja Fulton
Dori Reix
Ebony Rainge
Elizabeth Gardner
Emily Nicefaro
Gina Rodican
Jackie Acampora
John Parise
Kaye Henry
Kristen Rogers
Kristin Caceres
Layla Cesar
Lisa Stevenson
Louisa Meresko
Marisa Rambush
Megan Purvis
Melissa Lester
Meredith Lall
Pam Feroleto
Peter Samenfink
Rebecca Kazlauskas
Sarah Yagovane
Shayla Richardson
Starr Radin
Stephanie Swantek
Stephen Bagoly
Tara Wilczynski
Teyonda Davis
Tierra Soto
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?
*
Name:
*
Date
*
-
Month
-
Day
Year
Date
Submit
Should be Empty: