CaseBridges
Intake

Connection Intake Form

A brief intake to help us understand your needs and connect you with the right professional.

2-3 min Non-medical only Secure submission
* indicates a required field.

Demographics

        Gender *

        Therapy Needs

        Insurance & Email

          Privacy & Consent

          1. I understand this platform is not an emergency service. If I am in crisis, I will call 911 or 988.
          2. I understand CaseBridges does not provide medical, psychiatric, or therapeutic services.
          3. CaseBridges does not collect medical or diagnostic information. Please do not include any diagnosis, medical history, or psychiatric details.
          4. I consent to CaseBridges sharing my submitted information with verified mental health professionals solely for the purpose of referral and connection.