Secure Client Intake Form

Important Information Regarding Your Consultation

This Secure Intake Form serves as the single point of entry for all consultation services provided by BridgePointAccessibility. No Pre-Selection Required: You do not need to know the exact service you require (e.g., Virtual Assessment vs. Equipment Evaluation). Simply provide thorough answers, and we will guide you to the appropriate solution. Confidentiality: All information collected is protected under HIPAA standards and used solely for clinical assessment and service coordination. Next Steps: Upon successful submission, a representative from BridgePointAccessibility will review your information and contact you personally within 5 business days to discuss your needs and schedule the next step.

SECTION 1: CONTACT & ELIGIBILITY INFORMATION

First Name

Last Name

Date of Birth

mm/dd/yyyy

Email Address

If you do not have an emal address, please type "No Email"

Primary Phone Number

Secondary Phone Number

Home Address

Street, City, State, Zip

Are you currently an active participant in, or might you qualify for any of the Louisiana Medicaid Waiver Programs?

Yes No

IMPORTANT DISCLOSURE FOR WAIVER PARTICIPANTS

BridgePoint Accessibility is a private‑pay consulting service. To comply with state conflict‑of‑interest regulations that govern publicly funded disability services in Louisiana, BridgePoint Accessibility cannot provide services to individuals who may qualify or are participants in any Louisiana Medicaid Waiver Program or who receive home‑ and community‑based services funded through those programs.

Because individuals enrolled in these programs have access to similar services through publicly funded providers, accepting private payment from a Waiver participant would create a conflict of interest under the regulations that govern these programs.

As a result, BridgePoint Accessibility is unable to provide services to you at this time.

We strongly encourage you to connect with your Support Coordinator or Case Manager, who can help you access comparable services through approved providers within your Waiver network.

For more information or to discuss a potential referral to an appropriate provider, please feel free to email the owner directly: collin@bridgepointaccessibility.hush.com

SECTION 2: CLIENT & COORDINATOR DETAILS

Who is this form for?

I am completing this form for myself I am completing this form for another person

Relationship to Individual

Spouse, Parent, POA, Caregiver, Healthcare Provider, etc.

Name of Person Completing Form

Best Person to Contact for Service Coordination

Name, Phone Number, Email

Section 3: Clinical & Accessibility History (Health Profile)

Primary Medical Diagnoses

If you have no formal diagnoses, type "none"

Surgical History

Briefly list any surgeries, especially within the last 5 years or related to mobility

Height

If unsure, provide best estimate

Weight

If unsure, provide best estimate

Do you have a history of falls or near falls?

Yes No

If you have had falls or near falls, please briefly describe the circumstances

When did it happen? What is the frequency? Did injury occur? Any information on the circumstances are important.

If selected "Other" please specify

Vision and Hearing Deficits

No Deficits

Vision Impairment

Hearing Impairment

Is the vision deficit corrected with glasses or contacts?

Yes No A little bit

Briefly describe the vision deficits if you believe it affects safety

Is the hearing deficit currently corrected with a hearing aid?

Yes No A little bit

Briefly describe the hearing deficit if you believe it affects safety

SECTION 4: SERVICE NEEDS & GOALS

What is the primary reason you are seeking consultation?

Specific Areas of Concern in the Home

Kitchen

Primary Bathroom

Secondary Bathroom

Entryway/Exterior Access

Bedroom

Stairs/Exterior Access

Outdoor Accessibility

Other (specify)

Please specify the area of concern and any pertinent details

Are there any concerns with vehicle accessibility?

Yes No

Briefly specify concerns with vehicle accessibility

Personal Goals for this Consultation

What personal achievements or level of independence do you wish to accomplish?

Other Information Important for the Consultant to Know

Feel free to mention anything that you believe is important

Upload any relevant files here (optional) Medical record, medications, diagnoses, images of home, vehicle, or equipment, etc

Add file

Please upload a file

SECTION 5: REQUIRED CONSENTS & AUTHORIZATIONS

By checking the boxes below, I am providing my formal authorization and consent for the specified uses and disclosures of my Protected Health Information (PHI) by BridgePointAccessibility.

General HIPAA Authorization (use of PHI)

I authorize BridgePointAccessibility to use and disclose my health information (including clinical data, functional assessment results, and demographic details) for the purposes of providing consultation, coordinating project requirements, determining appropriate recommendations, and internal healthcare operations. I understand that the information I provide is considered Protected Health Information (PHI) under the Health Insurance Portability and Accountability Act (HIPAA). I acknowledge that I have been made aware of my right to receive a copy of BridgePointAccessibility’s Notice of Privacy Practices (which details how my information may be used and disclosed).

Information Sharing with Third Parties (Coordination of Care)

I authorize BridgePointAccessibility to release and exchange my relevant PHI, including assessment findings, project details, and contact information, with the following entities for the sole purpose of service coordination, project implementation, and equipment procurement: Contractors, Builders, and Remodelers - Medical Equipment Vendors and Suppliers - Referring Physicians or other Treating Clinicians. I understand that once information is disclosed to a third party, it may no longer be protected by federal privacy rules and that this authorization is necessary to proceed with effective consultation and project management.

Consent for Electronic Communication (Email & Text)

I understand and acknowledge the risks associated with using standard electronic communications, including the potential for unauthorized access, interception, or error. To facilitate efficient scheduling, coordination, and follow-up, I consent to receive non-urgent, routine administrative, and clinical information from BridgePointAccessibility via: Encrypted Email (via Hushmail): To the email address provided in Section 1. Text/SMS Messages: To the primary and/or secondary phone numbers provided in Section 1. I understand that while BridgePoint uses secure, HIPAA-compliant platforms (Hushmail) for communication, I am responsible for ensuring the security of my own electronic devices and email accounts.

Photography and Documentation Consent

I grant permission to BridgePointAccessibility to take and retain photographs, video recordings, or documentation of my home environment, and/or medical equipment/devices related to my consultation. I authorize the use of this documentation strictly for the following purposes: Confidential Client Record: For inclusion in my confidential client record and internal clinical review. Project Coordination: To be dispersed to authorized contractors, builders, remodelers, or equipment vendors only if necessary for the accurate coordination and implementation of the consultation recommendations. I understand that this documentation is essential for accurate assessment and communication with third-party service providers involved in my project.

Consent for Follow-up or Testimonials (Optional)

I grant permission for BridgePointAccessibility to contact me in the future (e.g., 6 or 12 months after project completion) to inquire about the long-term effectiveness of the consultation, or to request a formal testimonial regarding my experience.

Your information will be encrypted.