Community Resource Survey - Bridges of Hope

Are you a mental health provider?

Yes, I am the provider
No, I am recommending a provider

Mental Health Provider Information

Provider Name

First

Last

Email

Office Phone Number

Website / URL

What services do you offer?

Individual Counseling
Family
Group
Other

Other

What ages do you specialize in ?

Please select all that apply.

Other

What is your area of focus ?

Other

Location of the Office

Address Line 1

Address Line 2

City

State

Zip Code

I have a secondary location?

Location of the Office (Secondary Location)

Address Line 1

Address Line 2

City

State

Zip Code

Are you currently taking new clients?

Yes
No
Waitlist Available

Payment Information:

Self-Pay
Medicaid
Private Insurance
Sliding Fee Scale

Please select all that applies

Best way for a client to schedule:

Do we have permission to add this information on a Community Resource List ?

Yes
No

Additional Comments

Recommending a provider

Have you or someone you know received services from this person?

Yes
No

Do you know what forms of insurance they take?

Would you recommend this provider ?

Yes
No

Where is this provider located?

(Charleston, North Charleston, James Island, Ladson, Summerville ect.)

Do you have an email for the provider?

Do you have an phone number for the provider?

Website / URL (if known)

Additional Comments that would be helpful for us to know about the provider

Grief Support Groups

Do you know any grief support group being offered in our community ?

Yes
No

(other than Bridges/Stepping Stones)

Are you a Grief Support Group Leader?

Yes, I am a point of contact for this group.
No, I am sharing information about a group

Group Leader or Organization Contact Email

Group Leader or Organization Contact

Website / URL

Please provide any other known details about this group ?

Location, date, time, close vs open group, type of group or provider of the group

Bridges will be contacting all providers to schedule a 15 minute meet & greet to discuss the use of the list & verify all information provided prior to adding provider information.