New Client Inquiry - Gulf Coast Play Therapy Clinic, LLC
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THANK YOU for the inquiry!

Here is some information about the clinic:

 - I specialize in play therapy with children between the ages of 3 to 8 years old.

- I am only a provider for the following insurances: BCBS, SAS, First Choice, and Mississippi Physicians Care Network

- I currently only have weekly play therapy appointments available at 11:00 am. 1:00, 2:00, 3:00 and 4:00 pm slots are currently full, but once established as a client, you can be added to a later slot once it opens up. I do offer school and work excuses!

I can also add you to a waitlist if requested. 

If you are looking to get in with someone sooner, Jasmine Smith is another therapist trained in play therapy with more openings currently. She owns Stepping Stones Counseling, LLC and is currently sharing office space with Gulf Coast Play Therapy Clinic, LLC. Jasmine can be reached at steppingstoneslpc@gmail.com or 228-338-6769. Stepping Stones is a provider for the following insurances: BCBS, SAS, First Choice, United Healthcare, Aetna, and Cigna.

- **I do not have any administrative staff in the office** I am a small one clinician private practice and I respond to new client requests myself around my current caseload schedule. This can cause a delay in responding, but I will reach back out as soon as I am able. Sometimes e-mails go to spam, so check there also!

Please be sure to view my website: https://www.gcplaytherapy.com/ 
for additional information about play therapy and the clinic.

Once you hit submit, this form will automatically notify me.

THANK YOU!!

PLEASE MARK BELOW TO INDICATE YOU HAVE READ THE INTRODUCTORY INFORMATION. 

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E-Mail Address: *
Phone Number: *
Today's Date: *
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Please fill out this short form and Infanta will get in contact with you. Please note that due to daily client appointments, there is normally a delay in responding, but please be on the lookout for an e-mail or a voicemail. If you or your child is a danger to self or others or has a life threatening emergency, please contact 911. I am unable to provide crisis support services and this form is not monitored on a 24 hour basis.
Name of Person Completing Form: *
Name of Potential Client:
Date of Birth of Potential Client: *
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Did anyone refer you to our clinic? If so, who?
Is your child between the ages of 3-9? 
Please note: I only provide therapy services to children between these ages due to not currently offering traditional talk therapy. Please let me know if your child is over the age of 9 but may still be interested in a playroom.
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Very briefly, please describe your reason for seeking services for your child. If you prefer not to say, please indicate that. *
Do you currently have a court or custody case open that involves or could potentially involve your child in any way? **I am currently unable to provide treatment to anyone actively involved in divorce or custody proceedings. The court case must be settled. I would be happy to provide you with contact information of someone better suited for your needs. Please indicate if you would like this information in the “other” section below.** *

If parents are separated / divorced / divorcing, I do ask that both parents be invited to the intake and sign consent paperwork Unless there is some special circumstance that has occurred as to why this cannot or should not happen. 

CHILD'S Insurance Policy (I am only able to accept the insurances listed below): *
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Is there any additional information you would like for me to know?
It is essential to keep in mind that therapy is not a magic pill or a quick fix: therapy is a healing process that necessitates participation and investment. Play therapy is a commitment and requires consistency as much as possible. Many children that are in sports or other extra-curricular activities must attend practice multiple times a week to be successful. We only ask for less than one hour one time a week. With understanding that play therapy is a process, it is also important to note that while results are important and anticipated, your child’s growth can’t be hurried or pushed along. Some children demonstrate change quickly and others take a little longer, making it difficult to predict how many sessions a child will need. Please remember, we’re not looking for perfection – we’re looking for improvement. *
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