INDIVIDUAL — MIND THE GAP

Individual Therapy Request

Thank you for reaching out to me. If you are in need of immediate support, please call 911, go to your nearest emergency room, or contact our local crisis line at (360) 696-9560 or (800) 626-8137. Please take 5-10 minutes to complete the form below so that we may learn more about you and your current needs. I recognize that we are asking you to invest some time but our goal is to save you time in the long run. By helping me to learn more about you, I’m hoping to be able to get a better idea if we may be a good fit and if not, to help find somebody that is!

It takes some time for us to thoughtfully review requests but I aim to respond within a week. If I feel we are not best suited to meet your needs, I will do my best to respond with referrals to some options of people who may be a better fit. If I am accepting new clients and think I may be able to meet your needs, I will make a plan to set up a free 20 minute consultation to discuss working together.

Christine Griffiths, LMHC, CADC I,

Online Teletherapy Serving Washington Residence

503-750-5888

info@mindthegapcounseling.com

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Address

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1. Available therapy appointments vary but include different slots Monday through Friday with the first appt of the day beginning at 9:00am and the last appt beginning at 3pm. Will this work with your schedule?

*We may eventually have other openings but wanted to make you aware now so that you can determine best steps going forward. If you are not available on the days we currently have openings, you may check back with me of any changes!

2. Do you have access to reliable wifi, a smart phone, and/or a place to safely meet via telehealth?

All appointments are via telehealth at this time. We will provide you with a link to your appointment, so you do not have to be highly tech savvy but do need to have reliable wifi and a safe/private place to meet. Some clients use smartphones, some use computers. Some have private rooms to meet in and others meet in their cars, for example, in order to have a confidential space to talk.

3. Are you aware that we are not currently paneled with any insurance companies and charge $160 for a 50 minute appt?

*Please note that we reserve a limited number of sliding scale spots. If this is something you would like to explore further, please indicate this in the comments section at the end of this

4. Has someone in your life recommended therapy? If so, who and why?

5a. What are your reasons for seeking therapy at this time?

5b. What are some goals you are hoping to work on together during therapy appointments?

6. Have you previously received or do you currently identify with any sort of mental health diagnoses? If so, what diagnoses and do you feel they fit?

7. Are you taking any medications for mental health at this time? If so, what medications and how do you feel about them?

8. Are you concerned at all about your relationship with substances? If so, are you currently seeking support for these concerns?

9. Have you ever been in therapy before? If so, what did you like about it? What didn’t you like about it?

10. Do you have any cultural or other identities that are important for us to know about? If so, please tell us more.

11. What do you do for self-care?

12. Who or what do you consider to be supportive in your life at this time?

13. Please confirm having read and agreed to our policy regarding acute need below

If you are currently having serious thoughts of ending your life or have had serious suicidal thoughts or made attempts in the last 6 months, we are not able to begin a therapeutic relationship at this time. Our belief is that acute needs are best addressed by services able to provide more support and wrap-around care than is available through a small private practice. If you are in need of urgent care, please refer to the information provided at the top of this form or refer to our webpage for other referrals for wrap-around care.

14. Covid & Our Commitment to Public Health

As public health is a core value of Mind the Gap Counseling, we take a firm stance regarding Covid safety and believe in taking necessary steps toward protecting ALL community members. For the time being, all appointments will be conducted via telehealth. When it is safer to return to in-person services, we will require proof of vaccination, use of masks, and other risk-mitigation efforts to continue doing our part in keeping all community members as safe as we can. We will additionally continue to offer telehealth appointments to assure that mental health support continues to be accessible to all of our clients. We appreciate your understanding. I have read and understand Mind the Gap's Covid policies.

15. Is there anything else you feel is important for us to know at this time?

You made it through all of our questions! Thank you. Somebody will be in touch with you in about 24 - 48 hours.

16. I have read and understand North Coast Connection's Covid policies

Please choose one (you can elaborate more above if you wish!)