Request an Appointment | Bayfront Healthcare

Screening Form

Thank you for your interest and for contacting Bayfront Healthcare Services (BFHCS). We are dedicated to supporting those seeking changes in their life. BFHC offers outpatient mental health services which includes individual, family, and couple’s therapy. All services are provided through tele-health.

Our fees begin at $150.00 per hour for individual therapy and $200.00 for couples and family therapy.

In order to better understand your needs, please provide us with some brief background information on yourself. Please tell us if you’ve had any type of counseling or mental health services before.

First name

Last name

Date of Birth

Have you been hospitalized in the last 12 months?

Yes

Are you suffering from a medical condition, illness, or injury?

Yes

If you answered yes to any question, please elaborate

I declare that the info I’ve provided is accurate & complete

Initials

Thanks for submitting!