New Patient Inquiry Submission Form

Please Note:

Please note that Josie Bridges, LCSW is not currently accepting new minor clients whose guardians are in open, ongoing custody negotiations or those seeking court-ordered, forensic, or custody-related services, such as custody evaluations or services for the purpose of testimony in legal proceedings.

Please Review:

Please review our standard fees here, as all services are currently private pay.

Please note that by submitting this form, you are attesting that you are a legal guardian of the identified minor child and are voluntarily providing select health information for the purposes of inquiring about therapy services with Josie Bridges, LCSW. You are also consenting to being contacted at the number and email you submit.

Child's Name:*

Child's Date of Birth:*

Legal Guardian's Full Name and Relation to Child:*

Legal Guardian's Phone Number:*

Email*

Child's Primary Care Physician/Pediatrician:*

How were you referred to us?*

Please type your initials indicating that you have reviewed and understand our standard fees and private pay policy.*

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The TheraPlayce - Josie Bridges, LCSW

8211 Summa Avenue, Suite C, Baton Rouge, Louisiana 70809, United States

Email: contact@josiebridgeslcsw.com

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