Intake Questionnaire

Intake Questionnaire
Welcome to Bridge Family Therapy

We're glad you're here. This questionnaire is an important first step in establishing your care with us.

Why we ask these questions: Therapy works best when your therapist understands not just what brings you in, but the fuller picture of who you are — your history, your health, your relationships, your strengths. This information helps us meet you where you are and tailor our approach to your unique needs.

What to know before you begin:

Time: About 15-20 minutes, though some sections may not apply to you
Privacy: Your responses are confidential and protected under HIPAA
Saving: Your progress saves automatically — you can pause and return anytime
Honesty: Answer as openly as you feel comfortable; there are no right or wrong answers
Flexibility: If you'd rather discuss something in person than write it here, that's okay

This is the beginning of our work together. Thank you for trusting us with your story.

Questions? Contact us at admin@bridgefamilytherapy.com or 706-352-9199.

What Brings You to Therapy?

Information to help your therapist get to know you
What brings you to therapy at this time?*
Is there something specific, such as a particular event?
Have you ever experienced a traumatic or highly stressful event?*
If comfortable sharing, briefly describe the traumatic or highly stressful event
Examples: serious accident, natural disaster, violence, abuse, sudden loss
What are your goals for therapy?*
What would you like to be different as a result of therapy?

Medical & Physical Health

Information about current and past physical health
Physical Health
How would you rate your overall physical health?*
How would you rate your general sense of well-being?*
Do you have any physical health conditions or diagnoses? Take prescribed medications? Allergies?*

YesNo
Physical Health Condition Selection Table

Please use one of the two options below to select any physical health conditions
- OPTION 1 - List condition(s) - pre-populated options for severity and onset are located in the dropdown menus for each condition you list, add additional rows if necessary
- OPTION 2 - Pre-populated options for the condition(s), severity, and onset are located in the dropdown menus for each body system
- Medication History
- Are you currently taking any medications?*
  
  YesNo
- If you are currently taking medications please list
- If you have medications that you have discontinued please list
- Allergy History
- Do you have any known allergies?*
  
  YesNo
- If you currently have know allergies please list

Personal History & Lifestyle

Information to help your therapist get to know you
What is your highest level of education?
Current employment status
What is your current occupation?
What do you do? How long have you been doing it?
Are you currently dealing with any legal issues?*

YesNoPrefer Not to SayOther
If yes, are these related to concerns you want to address in therapy?
What interests, hobbies, and activities do you enjoy?
What are your sources of support?
Who do you turn to? (friends, family, community, faith, etc.)
What are your strengths?

Healthcare Information

Details about your healthcare team and insurance
Healthcare Providers

Please list your current healthcare providers. This information may be used to coordinate care with your permission.

	Provider Name	Practice/Clinic	Phone
Primary Care Physician
Psychiatrist
Other Mental Health Provider

Please list any additional healthcare providers you might have.
Insurance Information
Though therapy at Bridge Family Therapy is self-pay, we may assist with referrals where insurance information would be helpful. This section is optional.
Do you have health insurance?

YesNo
Primary Insurance Company
Member ID / Policy Number
Group Number
Insured's Name
Your Relationship to Primary Insured
Insured's Date of Birth

MonthDayYear
Date
Insured's Phone Number
Please enter a valid phone number.
Healthcare Collaboration Program
Bridge Family Therapy has developed a Healthcare Collaboration Program that provides targeted support to clients managing both mental and physical health concerns. If you found yourself spending significant time in the medical/health sections, this program may benefit you.
Would additional support managing your physical health within your mental health treatment be helpful?

Yes! This is very neededYes but I'd like more informationNot right now but maybe laterNot needed

Substance Use

Information about current and past substance consumption
The following questions help us understand any substance use that may be relevant to your treatment. Your honest answers help us provide the safest, most effective care.
Do you smoke or use nicotine products?
Do you drink alcohol?
Do you consume caffeine?
Cups of coffee or equivalent
Do you use pain medication daily?
Cups of coffee or equivalent
Do you use recreational drugs or other substances?*
Please select any recreational drugs or other substances you have use

Accessibility Preferences

Preferences or accommodations that would help you feel comfortable.
Do you require ground floor access? Utilize mobility devices?
e.g. wheelchair, crutches, etc.
Would you like to provide additional information regarding mobility?
Do you have preferences for the sensory environment? Sensory sensitivities?
e.g. natural lighting, music in office, etc.
Would you like to provide additional information regarding you sensory experience?
Do you have preferences for the physical environment?
e.g., difficult with stairs, sitting near the door, etc.
Would you like to provide additional information regarding the physical environment?
Do you have additional supports needs or preferences?
e.g., service animal, support person, etc.
Would you like to provide additional information regarding additional support needs?
* We make every effort to maintain consistency in room assignments. From time to time we have accessibility needs with our clientele that can lead to a room change being necessary.
Therapy Room - Please indicate your comfort level with the possibility of occasionally using a different therapy room:*

Family Therapy Information
What is the primary concern bringing your family to therapy?*
What does your family hope to achieve through therapy?
Describe your family's communication style
Are there any family members who are reluctant to participate?

YesNoUnsureOther
If yes, please explain
Please list the family member(s) name, relationship, age and if the family member will attend
Are there any custody, legal, or court-related considerations?

YesNoPrefer Not to SayOther
If yes, please explain
IMPORTANT: Please be prepared to provide documentation such as court orders, Power of Attorney documents, or letters of authority. You may be asked to provide these before or at the first session.
Consent:*

I understand I may be asked to provide legal documentation

Minor - Identification Details

Please provide information about the child who will be receiving therapy services.
Child's First Name*
Child's Middle Initial(s)
Child's Last Name*
Child's Preferred Name/Nickname
What does the child like to be called?
Child's Date of Birth*

MonthDayYear
Date
Child's Gender Identity
Pronouns
Sexuality (if applicable/known)
For adolescents, if known and relevant
Race
Ethnicity
Place of Birth
City, State/Country
Generation in the United States
Religious/Spiritual Affiliation
Currently Practicing?
Living Situation
Describe the child's current living situation
Does the child live with immediate family?*

YesNoOther
If yes, please list the name, age, and relationship

Minor - Primary Parent/Guardian Information
Parent/Guardian #1 First Name*
Parent/Guardian #1 Middle Initial(s)
Parent/Guardian #1 Name*
Parent/Guardian #1 Preferred Name
Parent/Guardian #1 Date of Birth*

MonthDayYear
Date
Relationship to Child*
Do you have legal custody of this child?*
Does the child live with you?*
Parent/Guardian #1 Primary Street Address*

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Parent/Guardian #1 Phone Number*
Please enter a valid phone number.
Parent/Guardian #1 Email*
example@example.com
Is there another parent/guardian who should be informed about treatment?*

YesNoOther
Parent/Guardian #2 First Name
Parent/Guardian #2 Middle Initial(s)
Parent/Guardian #2 Name
Parent/Guardian #2 Preferred Name
Parent/Guardian #2 Date of Birth

MonthDayYear
Date
Parent/Guardian #2 Relationship to Child
Does Parent/Guardian #2 also have legal custody of this child?
Parent/Guardian #2 Primary Street Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Parent/Guardian #2 Phone Number*
Please enter a valid phone number.
Parent/Guardian #2 Email*
example@example.com
Should this person receive communication about treatment?
Child's Primary Street Address (If Different from Parent/Guardian[s])

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Are there any custody orders, restrictions, or court involvement affecting this child's treatment?*

YesNoOther
If yes, please explain
Include any restrictions on who can consent, pick up the child, or receive information
IMPORTANT: We may need to verify your legal authority to consent to treatment on behalf of the client. Please be prepared to provide documentation such as court orders, Power of Attorney documents, or letters of authority. You may be asked to provide these before or at the first session.
Consent:*

I understand I may need to provide documentation of my legal authority

Minor - What Brings Your Child to Therapy
What brings your child to therapy at this time?*
Is there something specific, such as a particular event, change, or ongoing concern?
When did you first notice concerns about your child?
What are your goals for your child's therapy?*
What would you like to see change or improve?
What are your child's strengths?
What does your child do well? What do they enjoy?
Has the child ever experienced a traumatic or highly stressful event?*
If yes or unsure, briefly describe (if comfortable)
Examples: accident, loss, abuse, bullying, family changes, witnessing violence

Minor - Mental Health History

Information about your child's current and past mental health
Mental Health Conditions
Has your child been diagnosed with a mental health condition?*

YesNo
If yes, please list the diagnosis, severity, and date of diagnosis if known
Past Mental Health Services
Has your child received mental health services in the past?*

YesNo
If yes, please list the type of service, general outcome, and approximate dates
Mental Health Hospitalizations
Has your child ever been hospitalized for mental health reasons?*

YesNo
If yes, please list the hospital name, reason(s), and approximate dates
Does your child ever have thoughts of self-harm?*
Has your child ever attempted to self-harm?*
IF YOU ARE CURRENTLY IN CRISIS:

- Call or Text 988 (Suicide & Crisis Lifeline) — 24/7
- Text HOME to 741741 (Crisis Text Line)
- Georgia Crisis Line: 1-800-715-4225
- Go to your nearest emergency room
- Call 911 if you are in immediate danger

You matter. Help is available right now.

Minor - Substance Use

Information about current and past substance consumption
The following questions help us understand any substance use that may be relevant to your treatment. Your honest answers help us provide the safest, most effective care.
Does your child consume any of the following?*

NoNicotineAlcoholCaffeineNon-Prescribed Pain MedicationsRecreational DrugsOther
If you selected any of the above, please share any details you're comfortable providing — such as what is being consumed, how often, how long, and any changes you've noticed in your child's behavior or mood as a result.

Minor - Medical & Physical Health

Information about your child's current and past physical health
Physical Health
How would you rate your child's overall physical health?*
How would you rate your child's general sense of well-being?*
Does your child have any physical health conditions or diagnoses? Take prescribed medications? Allergies?*

YesNo
Physical Health Condition Selection Table

Please use one of the two options below to select any of your child's physical health conditions
- OPTION 1 - List condition(s) - pre-populated options for severity and onset are located in the dropdown menus for each condition you list, add additional rows if necessary
- OPTION 2 - Pre-populated options for the condition(s), severity, and onset are located in the dropdown menus for each body system
- Medication History
- Is your child currently taking any medications?*
  
  YesNo
- If your child is currently taking medications please list
- If your child has medications that they have discontinued please list
- Allergy History
- Does your child have any known allergies?*
  
  YesNo
- If your child currently has known allergies please list

Minor - Healthcare Information

Details about your child's healthcare team and insurance
Healthcare Providers

Please list your child's current healthcare providers. This information may be used to coordinate care with your permission.

	Provider Name	Practice/Clinic	Phone
Pediatrician
Psychiatrist
Other Mental Health Provider

Please list any additional healthcare providers your child might have.
Insurance Information
Though therapy at Bridge Family Therapy is self-pay, we may assist with referrals where insurance information would be helpful. This section is optional.
Does your child have health insurance?

YesNo
Primary Insurance Company
Member ID / Policy Number
Group Number
Insured's Name
Your Relationship to Primary Insured
Insured's Date of Birth

MonthDayYear
Date
Insured's Phone Number
Please enter a valid phone number.
Healthcare Collaboration Program
Bridge Family Therapy has developed a Healthcare Collaboration Program that provides targeted support to clients managing both mental and physical health concerns. If you found yourself spending significant time in the medical/health sections, this program may benefit you.
Would additional support managing your physical health within your mental health treatment be helpful?

Yes! This is very neededYes but I'd like more informationNot right now but maybe laterNot needed

Consent for Minor's Treatment
PARENT/GUARDIAN CONSENT FOR MINOR'S MENTAL HEALTH TREATMENT By signing below, I confirm that: 1. I am the parent or legal guardian of the child named in this intake form 2. I have legal authority to consent to mental health treatment for this child 3. I understand that therapy involves discussing personal and potentially sensitive topics 4. I agree to support the therapeutic process and participate as recommended 5. I have answered the questions in this form honestly and to the best of my knowledge 6. I understand that I will be asked to sign additional consent documents I hereby consent to mental health evaluation and treatment services for the above-named child at Bridge Family Therapy.
Signature

Clear
Parent/Guardian Name (printed)*
Relationship to Child
Minor Assent
MINOR'S ASSENT TO TREATMENT (Optional for ages 12+) If the child is old enough to understand and wishes to sign: I understand that I will be meeting with a therapist to talk about my thoughts, feelings, and experiences. I know that what I share is mostly private, but my parent/guardian and therapist may need to talk about some things to help keep me safe. I agree to try therapy.
Signature

Clear
Minor's Name (if signing)

Final Information & Signature
Is there anything else you would like us to know about you?
Any information that might help your therapist understand you better
DECLARATION I hereby declare that the information provided in this form is true and accurate to the best of my knowledge. I understand that this information will be used to inform my treatment at Bridge Family Therapy and will be kept confidential in accordance with HIPAA regulations. I understand that I can update or correct any information by contacting Bridge Family Therapy at admin@bridgefamilytherapy.com or 706-352-9199.
Full Legal Name (printed)*
Signature*

Clear
Should be Empty:

	Condition Present	Severity	Affected Family Member(s)
Alcohol or Substance Abuse
Anxiety
Depression
Bipolar Disorder
Eating Disorder
Obsessive-Compulsive Disorder
Schizophrenia or Psychotic Disorders
ADHD
Autism Spectrum
PTSD or Trauma-related
Suicide or Suicide Attempts
Sudden Unexpected Death

	Not at all	Several days	More than half the days	Nearly every day
Little interest or pleasure in doing things
Feeling down, depressed, or hopeless
Trouble falling or staying asleep, or sleeping too much
Feeling tired or having little energy
Poor appetite or overeating
Feeling bad about yourself — or that you are a failure or have let yourself or your family down
Trouble concentrating on things, such as reading the newspaper or watching television
Moving or speaking so slowly that other people could have noticed? Or the opposite — being so fidgety or restless that you have been moving around a lot more than usual
Thoughts that you would be better off dead, or of hurting yourself in some way

	(1) Yes	(2) No	(3) X
1. Did a parent or other adult in the household often swear at you, insult you, put you down, or humiliate you? Did they act in a way that made you afraid that you might be physically hurt?
2. Did a parent or other adult in the household often push, grab, slap, or throw something at you? Did they ever hit you so hard that you had marks or were injured?
3. Did an adult or person at least 5 years older than you ever touch or fondle you or have you touch their body in a sexual way? Did they try to or actually have oral, anal, or vaginal sex with you?
4. Did you often feel that no one in your family loved you or thought you were important or special? Did you often feel as your family didn’t look out for each other, feel close to each other, or support each other?
5. Did you often feel that you didn’t have enough to eat, had to wear dirty clothes, and had no one to protect you? Did you often feel that your parents were too drunk or high to take care of you or take you to the doctor if you needed it?
6. Were your parents ever separated or divorced?
7. Were either of your parents often pushed, grabbed, slapped, or had something thrown at her? Were they sometimes or often kicked, bitten, hit with a fist, or hit with something hard? Or ever repeatedly hit over at least a few minutes or threatened with a gun or knife?
8. Did you live with anyone who was a problem drinker or alcoholic or who used street drugs?
9. Was a household member depressed or mentally ill or did a household member attempt suicide?
10. Did a household member go to prison?

	Condition Present	Severity	Affected Family Member(s)
Alcohol or Substance Abuse
Anxiety
Depression
Bipolar Disorder
Eating Disorder
Obsessive-Compulsive Disorder
Schizophrenia or Psychotic Disorders
ADHD
Autism Spectrum
PTSD or Trauma-related
Suicide or Suicide Attempts
Sudden Unexpected Death

Services Requested

How Did You Hear About Us?

Guardian/Representative Information

Personal Information

Living Situation

Emergency Contact

What Brings You to Therapy?

Mental Health History

Current Concerns

Mental Health Conditions

Past Mental Health Services

Mental Health Hospitalizations

Medical & Physical Health

Physical Health

Physical Health Condition Selection Table

Medication History

Allergy History

Personal History & Lifestyle

Family Health History

Family Physical Health History

Family Physical Health Condition Selection Table

Family Mental Health History

Childhood Family Structure

Healthcare Information

Healthcare Providers

Insurance Information

Healthcare Collaboration Program

Substance Use

Brief Depression Screening

Childhood Experiences Survey

Relationship Structures Survey

Accessibility Preferences

Relationship Therapy Information

Family Therapy Information

Minor - Identification Details

Living Situation

Minor - Primary Parent/Guardian Information

Minor - What Brings Your Child to Therapy

Minor - Current Concerns

1. Everyday Functioning

2. Mood & Emotions

3. Anxiety & Fears

4. Social & Relational

5. Behavioral Concerns

6. Thoughts & Cognition

7. Body & Physical

8. Development & Neurodivergence

9. Identity & Development

10. Trauma & Adverse Experiences

11. Family & Life Changes

Minor - Mental Health History

Mental Health Conditions

Past Mental Health Services

Mental Health Hospitalizations

Minor - Substance Use

Minor - Medical & Physical Health

Physical Health

Physical Health Condition Selection Table

Medication History

Allergy History

Minor - Healthcare Information

Healthcare Providers

Insurance Information

Healthcare Collaboration Program

Minor - Family Health History

Family Physical Health History

Family Physical Health Condition Selection Table

Family Mental Health History

Minor - School & Development

Consent for Minor's Treatment

Minor Assent

Final Information & Signature