Patient Demographics

Patient First Name(Required)

Patient Middle Name

Patient Last Name(Required)

Address(Required)

Street Address Address Line 2 City State ZIP Code

Home Phone(Required)

Cell Phone

Email(Required)

Insurance

Primary Insurance

Company Name

ID #

Phone #

Secondary Insurance

Company Name

ID #

Phone #

*EMAIL ID AND INSURANCE CARDS TO scheduling@bridgepointclinic.com*

Visit Information

Reason for Visit/Current Diagnosis

Primary Care or Referring Doctor

Phone #

Family Members at home

(Spouse, Parents, Children, Siblings, Other)

Current Medical Illnesses

Medication Allergies(Required)

Current Pharmacy

List all CURRENT medications

(include dosage and frequency)

List all PRIOR Psychiatric medications

(include dosage and frequency)

Prior Psychiatric History

(Inpatient Admission, Previous Providers, Prior Dx, Testing, Etc...)

Signature Acknowledgement

Your signature acts as a comprehensive signature acknowledgement for the following forms and policies. These forms have been sent to you through the patient portal, are available on the website, and can be printed for you at your request. You further acknowledge that you have read, understand, and accept each policy in its entirety.

HIPAA Form • Controlled Substance Agreement • Payment Policy • Treatment Consent

Print Name(Required)

Date(Required)

Start Your JourneyContact Us!

Complete this form so we can assist with your mental health journey.