Contact | The Bridge Counseling

General Information

Client's - Full Name

Legal Guardian's - Full Name

If client is a minor... this field must be completed. Client's under the age of 18 will not be contacted directly.

Client's - Date of Birth

Month

Day

Year

Phone Number

If client is a minor please put the number of the Legal Guardian listed above...

Email Address

If client is a minor please put the email address of the Legal Guardian listed above...

When are you looking to schedule appointments?

Morning (8am - 12pm)

Afternoon (12pm - 3pm)

Evening (3 pm - 6pm)

Are you looking for in person sessions or telehealth sessions?

In person (Chantilly, VA)

Telehealth

How would you like to pay for sessions?

Insurance (Anthem/BCBS, Aetna, United Healthcare, etc.)

Self-Pay (online payments only)

Has the client been to out-patient therapy in the past?

Yes

Give us a little information on what brings you into therapy and what you're hoping to get out of this process...