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Psychology Intake Form - Current Wait Time: 6-7 months
Bridgeway Therapy Center’s Mental Health Department is pleased to offer:
  • Low wait times for assessments
  • Professional staff with expertise in evaluating children and adults
  • A supportive environment that celebrates and affirms neurodiverse minds
Assessment services include initial diagnostic assessments, progress monitoring, and evaluation for co-occurring conditions/new concerns.

Bridgeway Therapy Center specializes in evaluating children, teens, and adults for the following:
  • Autism (even subtle presentations)
  • ADHD
  • Behavioral Disorders
  • OCD
  • Depression
  • Anxiety 
  • Mood Disorders
  • Intellectual Disabilities
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Date *
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Person filling out the form (if not the parent): *
If you answered "other", please indicate your relationship/role below:
Client's Name *
Gender: *
Date of Birth *
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Parent/Caregiver FIRST Name: (type "self" if this evaluation is for yourself, not for your child) *
Parent/Caregiver LAST Name: (type "self" if this evaluation is for yourself, not for your child)
Contact Phone Number *
Contact Email Address *
Home Address: *
Home Address city, state, zip:
Prior Diagnoses?  *
Required
What areas of concern do you have currently (e.g., what will this evaluation look for)? Check all that apply: *
Required
If still in school, does this child have an ETR, IEP, or 504 Plan on file? *
Required
If this child was found to be eligible for special education services, please select the category:
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Referred by (if applicable)
Method of payment *
If you selected "insurance", please list your provider (these are the only plans we currently accept):
How did you find us? *
Thank you for completing this form!  You will only be contacted when your family's name has come up on the waitlist for an evaluation slot.  Otherwise, rest assured that the psychologists have received your contact information once you click "submit".
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