New Patient Intake Form
Welcome new patients! Please complete the
intake form below and click submit.  The form
below includes necessary information required for
an initial patient intake. It is very important to
complete the entire intake form so we may better
serve you. A staff member will contact you within
24 hours or the next business day to discuss
scheduling and treatment needs.
We are here to work with you!

Upon scheduling an initial appointment, the Bridges'
staff will make every effort to meet the various needs
of patients and provide quality care. Please notify
staff of scheduling conflicts and we will attempt to
accommodate your needs.  If you are not satisfied
with the  services  provided by the Bridges' staff upon
the initial appointment; please notify the front staff
and/or request a New Patient Survey. The Executive
Director will contact you to assist in resolving the
issue.
New Patient Information:

Please complete the information below as truthfully as possible. If a specific option or question does not apply to you,
please enter N/A in the text box. All information that is entered will be kept strictly confidential.
Full Name:
Date of Birth (MM/DD/YYYY):
Contact Numbers:
Please give two telephone numbers so that our staff may contact you. Provide a description of each (i.e. cell, home, work).
Contact Preference:
Email Address:
Complete Mailing Address:
Please select the type of service that you are seeking:
Employment Status:
If you are employed or a student, where?
Marital Status:
Race/Ethnicity:
Preferred Language:
Gender:
Highest Level of Education Completed:
Have you been hospitalized for illness regarding mental health? If yes, when and
where?
Have you received mental health treatment in the past or are you currently in treatment
for your mental health? If yes, where?
What type of issues have you experienced which prompted you to seek mental health
treatment?
Current Medications: please list any medications that you are currently taking.
Medical History: please list any current or prior health conditions including (but not
limited to), major surgeries, health conditions, or mental health disorders.
In the past 6 months, have you been homicidal?
In the past 6 months, have you been suicidal?
Please list, if applicable, your insurance carrier, member ID number, group number, and
insured party's name, date of birth, employer, and phone number (if you are not the
insured party).
If you also have secondary or tertiary insurance coverage, please specify below and
answer the aforementioned questions for your additional insurance plans.
Primary Care Physician:
How did you hear about our facility? If you were referred, by whom?
Please list an emergency contact name & number:
If you are completing this form  for your dependent, please provide your name and
number, your relationship to the individual, and an additional emergency contact.
If you are completing this form for someone who is NOT your dependent, please list
your name and number and specify your relationship to the individual.
**Please bring photo ID, insurance cards and co-pay at time of appointment.**

Submit Intake Form