Bridging Hope Therapy Interest Form
Bridging Hope (formerly Rape Response) provides free trauma focused therapy for individuals ages 13+ who have been impacted by sexual trauma and live in our agency's service area (Hall, Dawson, Forsyth, Lumpkin, Habersham and White Counties in Northeast Georgia). 

Please complete this form if you are interested in therapy services at Bridging Hope.

Please note that our waitlist has several people on it and it may be one or more months before a spot becomes available. If you would like additional support in the meantime, please call our crisis line to connect with an advocate at (770) 503-7273. Advocates are available 24/7 to provide support. 
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What is your full name? *
How should we refer to you/what pronouns do you use? (Examples: She/Her, He/Him, They/Them, She/They) *
What is your birthdate? *
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For those younger than 18, please share your parent/guardian's name and contact information. We must have your guardian's consent to provide services.
What language(s) do you speak? What language are you seeking therapy services in? *
What is your address? Please include city, state and zip code. *
What county do you reside in? (Dawson, Hall, Habersham, Lumpkin, Forsyth or White) *
What is your phone number?
What is your email address? *
What is your preferred method of communication? *
Required
Do we have permission to contact you using this method?

(Please note if there are any special considerations we should take when texting or leaving you a voicemail.) *
What is your estimated annual income? Your answer is utilized for grant purposes only.  *
Are you currently working with a Bridging Hope advocate? If so, please list your advocate's name.
What days and times during the week are you able to attend sessions? Please note: Saturday and evening session availability is limited, so please provide as many options as possible.  *
Do you have a preference for what gender your therapist is? *
Do you currently have thoughts of hurting yourself or another person? *
If you answered sometimes, often, or always to the previous question, do you have a plan or intention to hurt yourself or another person?
Please provide a brief description of why you are seeking counseling at this time. What do you hope to gain from the counseling experience? *
Are there any barriers that you foresee that would limit your ability to participate in counseling sessions (for example: transportation challenges, childcare, etc.)? *
Therapy services at Bridging Hope are covered by grant funding and are offered to clients at no charge. As there is a high demand for mental health services in the community, we may provide you with referrals in order to connect you as quickly as possible with trauma informed providers. 

If you have reported a crime/incident of sexual abuse/assault, you may be eligible for financial coverage for therapy through the Georgia’s Crime Victim’s Compensation Program. If you have made a police report, our advocates can assist you in applying for this benefit and connecting with therapist's who accept CVCP. 

If you have health insurance that covers mental health care, we can assist you in finding a therapist who accepts your insurance. 

The following information will assist us in connecting you with the most appropriate provider. Please mark if any/all apply to you:
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Required
Do you have any questions or concerns about therapy at Bridging Hope?
I understand that there is a waiting list for Bridging Hope Therapy Services and I consent to being emailed to confirm I am on the waiting list and to receive an estimated wait time. This could be 1+ months from now. In the meantime, I understand that Advocacy services and support are available 24/7 by contacting the Bridging Hope crisis line at 770-503-7273. *
Required

Mobile SMS Messaging Privacy Policy

Messaging Terms & Conditions: You agree to receive informational messages (appointment reminders, account notifications, etc.) from Bridging Hope. Message frequency varies. Message and data rates may apply. For help, reply HELP or email us at info@bridginghopega.org. You can opt out at any time by replying STOP. Information collected: We may collect information, such as name, phone number, and email address. Use of information collected: We may use the information we collect to perform the services requested including billing, customer service, appointment reminders and other administrative requests.

Sharing of information collected: We may share information we collect with payment processors, legal authorities, partners so that these service providers can perform their normal duties. We do not share, sell, rent, or trade any information provided with third parties for promotional purposes. As a current or prospective customer, you understand that you can text us STOP at any time to opt out of receiving SMS text messages from us. You can text us HELP at any time to receive help. You understand that the messaging frequency may vary. Messaging & data rates may apply. Your mobile information will not be shared with any third parties/affiliates for marketing/promotional purposes. All policies are followed as per CTIA guidelines 5.2.1. At any time if you want your information to be removed, you can contact us via our email address or regular mail.

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