Intake Questionnaire - Bridge Family Therapy - v2

  • 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.

  • Services Requested

    Select the service, format and referral source
    Services Requested
  • What type(s) of therapy services are you interested in?*
  • Are you filling out this form on behalf of someone else?*
  • Do you have a preferred format or mode for sessions?*

  • How Did You Hear About Us?

  • How did you hear about Bridge Family Therapy?*

  • Guardian/Representative Information

    For Guardian(s) or Representative(s) of Adults
    Guardian/Representative Information
  • Format: (000) 000-0000.
  • What type of legal authority do you have?
  • Is your legal authority documented in court records?*
  • 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.

  • Personal Information

    Basic Demographics
    Personal Information
  • Date of Birth*
     - -
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Preferred Contact Method*

  • Living Situation

  • Do you live with immediate family?*

  • Emergency Contact

  • Format: (000) 000-0000.
  • Is this person aware they are listed as your emergency contact?

  • What Brings You to Therapy?

    Information to help your therapist get to know you
    What Brings You to Therapy?

  • Current Concerns

    Current Concerns
  • Please review each category and indicate whether you have concerns in that area. If yes, select any specific experiences that apply.

  • 1. Mood & Emotions

    Sadness, emotional numbness, irritability, mood swings, guilt, hopelessness
  • Do you have concerns in this area?*
  • Please select any that apply:

  • 2. Anxiety & Worry

    Worry, panic, social anxiety, phobias, tension, avoidance
  • Do you have concerns in this area?*
  • Please select any that apply:

  • 3. Trauma & Past Experiences

    Flashbacks, nightmares, hypervigilance, avoidance, trust difficulties
  • Do you have concerns in this area?*
  • Please select any that apply:

  • 4. Relationships & Social Functioning

    Conflict, isolation, codependency, boundaries, communication, loneliness
  • Do you have concerns in this area?*
  • Please select any that apply:

  • 5. Self-Worth & Identity

    Self-esteem, perfectionism, people-pleasing, identity, self-compassion
  • Do you have concerns in this area?*
  • Please select any that apply:

  • 6. Behavioral Concerns

    Anger, impulsivity, self-harm, compulsions, avoidance, addictive patterns
  • Do you have concerns in this area?*
  • Please select any that apply:

  • 7. Work & Academic Functioning

    Burnout, concentration, performance, career, work-life balance
  • Do you have concerns in this area?*
  • Please select any that apply:

  • 8. Sleep & Energy

    Insomnia, fatigue, nightmares, irregular schedule, low motivation
  • Do you have concerns in this area?*
  • Please select any that apply:

  • 9. Grief & Loss

    Death, relationship loss, health loss, unresolved grief, life changes
  • Do you have concerns in this area?*
  • Please select any that apply:

  • 10. Physical Symptoms & Health

    Chronic pain, somatic complaints, health anxiety, appetite, body image
  • Do you have concerns in this area?*
  • Please select any that apply:

  • 11. Life Transitions & Adjustment

    Major changes, parenthood, divorce, financial stress, aging
  • Do you have concerns in this area?*
  • Please select any that apply:

  • Mental Health History

    Mental Health History
  • Have you been diagnosed with a mental health condition?*

  • Past Mental Health Services

  • Have you received mental health services in the past?*

  • Mental Health Hospitalizations

  • Have you ever been hospitalized for mental health reasons?*


  • 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.

  • Medical & Physical Health

    Information about current and past physical health
    Medical & Physical Health

  • Physical Health

  • Do you have any physical health conditions or diagnoses? Take prescribed medications? Allergies?*

  • Physical Health Condition Selection Table

    Please use one of the two options below to select any physical health conditions
    • OPTION 1 - Manually List Conditions 
    • END 
    • OPTION 2 - Select Conditions from Pre-populated Lists 
    • END 

    • Medication History

    • Are you currently taking any medications?*

    • Allergy History

    • Do you have any known allergies?*

  • Personal History & Lifestyle

    Information to help your therapist get to know you
    Personal History & Lifestyle
  • Are you currently dealing with any legal issues?*

  • Family Health History

    Information about current and past family health
    Family Health History

  • Family Physical Health History

  • Is there a history of physical health conditions in your family?*

  • Family Physical Health Condition Selection Table

    Please use one of the two options below to select any physical health conditions
    • OPTION 1 - Manually List Conditions 
    • END 
    • OPTION 2 - Select Conditions from Pre-populated Lists 
    • END 

    • Family Mental Health History

    • Is there a history of mental health conditions in your family?*
    • Rows

    • Childhood Family Structure

  • Healthcare Information

    Details about your healthcare team and insurance
    Healthcare Information

  • Healthcare Providers

  • Rows

  • 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?
  • Insured's Date of Birth
     - -
  • Format: (000) 000-0000.

  • 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?

  • Substance Use

    Information about current and past substance consumption
    Substance Use
  • 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.

  • Brief Depression Screening

    Patient Health Questionnaire
    Brief Depression Screening
  • Rows

  • Source: Kroenke, K., Spitzer, R. L., & Williams, J. B. (2001)

  • Childhood Experiences Survey

    Adverse Childhood Experiences Questionnaire
    Childhood Experiences Survey
  • Rows

  • Source: CDC-Kaiser Permanente ACE Study, 1998

  • Relationship Structures Survey

    Experiences in Close Relationships Questionnaire
    Relationship Structures Survey
  • Please read each statement and indicate how much you agree or disagree as it relates to your close relationships (romantic partners, close friends, family). There are no right or wrong answers.
  •

  • Source: Fraley, Heffernan, et al. (2011)

  • Accessibility Preferences

    Preferences or accommodations that would help you feel comfortable.
    Accessibility Preferences

  • * 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.

  • Relationship Therapy Information

    Relationship Therapy Information
  • Please note: While you may be asked to discuss your answers in session, the person you're in a relationship with will NOT be shown this form. Your responses are confidential.
  • Have you received couples/relationship therapy before?*
  • RELATIONSHIP THERAPY POLICY If you are here to work on relationship issues or goals, please understand: 1. Your therapist does not have preconceived notions about what should happen in your relationship(s). We explore relationships openly, honestly, and thoroughly. 2. Once your goals are established, your therapist will work diligently to support you in achieving them, whatever they may be. 3. You authorize your therapist to use professional judgment regarding individual confidences. Information you communicate individually (by phone, email, or other means) may be important to bring up in a relationship therapy session, and the therapist reserves the right (but not the obligation) to do so.

  • Family Therapy Information

    Family Therapy Information
  • Are there any family members who are reluctant to participate?
  • Are there any custody, legal, or court-related considerations?

  • 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.

  • Minor - Identification Details

    Please provide information about the child who will be receiving therapy services.
    Minor - Identification Details
  • Child's Date of Birth*
     - -

  • Living Situation

  • Does the child live with immediate family?*

  • Minor - Primary Parent/Guardian Information

    Minor - Primary Parent/Guardian Information
  • Parent/Guardian #1 Date of Birth*
     - -
  • Format: (000) 000-0000.
  • Is there another parent/guardian who should be informed about treatment?*
  • Parent/Guardian #2 Date of Birth
     - -
  • Format: (000) 000-0000.
  • Are there any custody orders, restrictions, or court involvement affecting this child's treatment?*

  • 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.

  • Minor - What Brings Your Child to Therapy

    Minor - What Brings Your Child to Therapy

  • Minor - Current Concerns

    Minor - Current Concerns

  • Please review each category and indicate whether your child is currently experiencing concerns in that area. If yes, you'll be able to select specific items.

  • 1. Everyday Functioning

    Sleep, concentration, school, appetite, screen time
  • Does your child have any concerns in this area?*
  • Please select any that apply

  • 2. Mood & Emotions

    Sadness, worry, mood swings, self-worth
  • Does your child have any concerns in this area?*
  • Please select any that apply

  • 3. Anxiety & Fears

    Separation, phobias, avoidance, reassurance-seeking
  • Does your child have any concerns in this area?*
  • Please select any that apply

  • 4. Social & Relational

    Friendships, bullying, social skills, sibling conflict
  • Does your child have any concerns in this area?*
  • Please select any that apply

  • 5. Behavioral Concerns

    Temper, defiance, aggression, impulsivity
  • Does your child have any concerns in this area?*
  • Please select any that apply

  • 6. Thoughts & Cognition

    Intrusive thoughts, repetitive behaviors, racing thoughts
  • Does your child have any concerns in this area?*
  • Please select any that apply

  • 7. Body & Physical

    Eating, body image, unexplained pain, tics
  • Does your child have any concerns in this area?*
  • Please select any that apply

  • 8. Development & Neurodivergence

    Sensory, routine, communication, coordination
  • Does your child have any concerns in this area?*
  • Please select any that apply

  • 9. Identity & Development

    Gender, sexuality, cultural identity, puberty
  • Does your child have any concerns in this area?*
  • Please select any that apply

  • 10. Trauma & Adverse Experiences

    Abuse, neglect, violence, loss, instability
  • Does your child have any concerns in this area?*
  • Please select any that apply

  • 11. Family & Life Changes

    Divorce, grief, caregiver stress, system involvement
  • Does your child have any concerns in this area?*
  • Please select any that apply

  • Minor - Mental Health History

    Information about your child's current and past mental health
    Minor - Mental Health History
  • Has your child been diagnosed with a mental health condition?*
  • Has your child received mental health services in the past?*
  • Has your child ever been hospitalized for mental health reasons?*

  • Minor - Substance Use

    Information about current and past substance consumption
    Minor - Substance Use
  • 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?*

  • Minor - Medical & Physical Health

    Information about your child's current and past physical health
    Minor - Medical & Physical Health

  • Physical Health

  • Does your child have any physical health conditions or diagnoses? Take prescribed medications? Allergies?*

  • 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 - Manually List Conditions 
    • END 
    • OPTION 2 - Select Conditions from Pre-populated Lists 
    • END 

    • Medication History

    • Is your child currently taking any medications?*

    • Allergy History

    • Does your child have any known allergies?*

  • Minor - Healthcare Information

    Details about your child's healthcare team and insurance
    Minor - Healthcare Information

  • Healthcare Providers

  • Rows

  • 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?
  • Insured's Date of Birth
     - -
  • Format: (000) 000-0000.

  • 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?

  • Minor - Family Health History

    Information about your child's current and past family health
    Minor - Family Health History

  • Family Physical Health History

  • Is there a history of physical health conditions in your child's family?*

  • Family Physical Health Condition Selection Table

    Please use one of the two options below to select any physical health conditions
    • OPTION 1 - Manually List Conditions 
    • END 
    • OPTION 2 - Select Conditions from Pre-populated Lists 
    • END 

    • Family Mental Health History

    • Is there a history of mental health conditions in your child's family?*
    • Rows

  • Minor - School & Development

    Minor - School & Development
  • Does your child have an IEP (Individualized Education Program)?
  • Does your child have a 504 Plan?
  • Has your child been diagnosed with or evaluated for any of the following?
  • Has the child received any educational or psychological evaluations?
  • Does the child receive any school-based services?

  • Minor - Pediatric Symptom Checklist (PSC-17)

    Parent-Report Behavioral & Emotional Screening
    Minor - Pediatric Symptom Checklist (PSC-17)
  • Almost done. This brief questionnaire helps your child's therapist understand where your child is right now. There are no right or wrong answers.
  • Please indicate how often your child has experienced each of the following behaviors over the past month. There are no right or wrong answers 6 your honest responses help your child's therapist understand where they are right now.
  • Rows
  • Rows
  • Rows

  • Minor - Accessibility Preferences

    Preferences or accommodations that would help you feel comfortable.
    Minor - Accessibility Preferences

  • * 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.

  • Family-Systems Partnership

    The principles that guide how we work with families.
    Family-Systems Partnership

  • A child’s growth in therapy is deeply connected to what happens in the rest of their life—at home, at school, in their community, and in every system they navigate.

    You are doing something meaningful for your child, and we're grateful you're trusting us to be part of it. Please share your honest response to each section — your child's therapy begins either way.

    Read the full partnership document.

  • 1. Our Approach

  • We work through a family-systems lens, meaning we consider the full picture of your child's life — not just what happens in the therapy room. We are an affirming practice, we use play and creative techniques as evidence-based therapy, and we actively advocate on your child's behalf with schools, doctors, and other providers.*

  • 2. Your Role

  • Your involvement in your child's therapy is essential — the skills your child develops in session need to be reinforced at home and across their environments. We ask families to commit to five principles: protect your child's role as a child, create emotional safety, support the process, engage as a partner, and validate your child's experiences.*

  • 3. The Therapeutic Relationship

  • We maintain confidentiality in our work with your child while keeping you informed about progress, goals, and safety concerns. We honor your child's assent — their willingness to participate — and we clearly establish legal guardianship and consent before treatment begins.*
  • Do you child's parents or legal guardians live in separate households?
  • Do you have the legal authority to consent to your child's therapy?

  • 4. Co-Parenting & Your Child's Wellbeing

  • Your child should never be placed in the middle of parental conflict, and both parents support therapy regardless of personal disagreements. All communication from Bridge Family Therapy goes to both legal caregivers equally, and therapy will not be used in custody disputes.

  • Consent for Minor's Treatment

    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.

  • 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.
  • Final Information & Signature

    Final Information & Signature

  • 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.

  • Client Authorization

    Please read and sign the authorization below
  • I hereby authorize Bridge Family Therapy to release information to and receive information from the following individuals or entities as necessary for my treatment and care. This authorization is valid until revoked in writing.
  • Authorization Expiration Date*
     - -
  • Date Signed*
     - -
  • Should be Empty: