Intake Form

Client Information

Full Name
Address
Preferred Method of Contact

Categories and Services

Client Category (Select all that apply)
Services Requested (Select all that apply)

Background Information

Are you currently receiving any support services?

Additional Contact

Additional Contact

Emergency Contact

Additional Supports

Do you need help with any of the following?

Consent & Agreements

Confidentiality Agreement
I understand that all personal information will be kept confidential and used only for service coordination.
Service Authorization
I authorize Bridging the Gaps Corporation Inc. to provide support services and communicate with relevant agencies/schools as needed.

Optional Documents Upload

Multiple Choice
Drag & Drop Files, Choose Files to Upload

Referral Source

Referral Source
=
Scroll to Top