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Psychology Intake Form - Current Wait Time: 5-6 months
Bridgeway Therapy Center’s Mental Health Department is pleased to offer:
  • Low wait times for assessments (approx. 5-6 months)
  • Professional staff with expertise in evaluating children and young adults
  • A supportive environment that celebrates and affirms neurodiverse minds
Assessment services include initial diagnostic assessments, progress monitoring, evaluation for co-occurring conditions/new concerns, and Independent Educational Evaluations.

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 (60-90 days).  Otherwise, rest assured that the psychologists have received your contact information once you click "submit".
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