Registration

Please watch our short orientation video before deciding to continue to the registration form

First Name

DOB

Last Name

Preferred Pronouns

Street Address

Street Address Line 2

City

State

Zip code

Phone

Program(s) being referred to

Referral Source Name

Please note that completing your intake online requires the use of a computer to complete the necessary paperwork, it can not be completed on your phone or tablet.

Additional Notes

Please upload a clear photo of your face. (Please note that your referral source will be able to see this photo)

Upload Photo

I agree to follow through with the remainder of my intake process when I receive the next steps

I give you permission to communicate with my referral source about my case.

*This authorization is good for 60 days.

Welcome to the program! Check your inbox for proof of registration. You will also receive an email with the next steps for your program intake.

Notes

You will immediately receive an e-mail which provides proof of enrollment.
You will immediate receive a second e-mail titled 'Enrollment - Next Steps' which will provide you with the next steps.
- If you chose to complete your intake in person, we will reach out to you within two business days.
- If you chose to complete your intake online: within two business days of receiving your intake payment, you will receive the intake documents via Adobe Sign. Please fill out the packet completely (be sure to read through the assessment questions and change the drop down answers to the appropriate answer to ensure that you are accurately assessed) and then submit. Once you have completely filled out the packet there will be a blue banner across the bottom of the screen which will say Adobe Sign Click to Sign: clicking this will submit the documents and you will immediately receive a copy.
  - Within two business days of us receiving your completed documents you will receive another e-mail, titled 'Enrollment - Next Steps 2' from office@bridges2success.com, asking for you to choose your group and start date. We ask that you start within two weeks. This e-mail will also include office hours for you to pick up your workbook and get answers to any questions you may have.

If at any time you do not see the e-mails, please check your spam/junk folder.

Please keep in mind that you are welcome to e-mail/call us with any questions, at any time, and/or attend an informational session which will be listed in each e-mail that you receive from our office.

We highly recommend saving our contact information in your phone so that we can communicate easily:

Phone: 1 (800) 509-0794

E-Mail: office@bridges2success.com

Please continue to the registration form and we look forward to working with you!