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Registration is only required if you do not have a username. Please check your spam & junk mail folders to ensure you have not already received an email with a username and password. If you already have a username log in here

Each account must have a unique email address associated with it. Please contact us if you need multiple accounts with the same email address (i.e. related family members).

Welcome to Bridge to Mental Wellness! I know your time and resources are very valuable. So, I hope to continue to create intake paperwork that allows us to utilize our face to face time efficiently and also give you an opportunity to share with me significant information to make our work together the most effective. Please let me know if you have any questions. You can also text me at 317-830-0408 with any questions if needed too.

Client Information

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( MM-DD-YYYY )

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( for Text Message Reminders )

Bill To Contact

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Emergency Contact

First Name
Last Name
Phone
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Relation
Email
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City
State
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( If client is a minor, the legal guardian must enter their email address below. )



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( If you feel you must write down your questions in order to remember them, make sure to keep it in a safe place. )