2026 Intake Interview Questionnaire

This is an intake and screening document. It is separate from the Service Contract and required acknowledgements. Each Custodial/Receiving Parent (CP), Non-Custodial/Visiting Parent (NCP), or other adult participant who will be present should complete a separate questionnaire.

Open Fillable PDF Service Contract

Before your intake meeting: Please provide current court orders and any applicable protection/restraining orders through the Request Services process or as otherwise directed by Bridging Families.

Privacy: This questionnaire asks for sensitive case, legal, safety, and health information. Do not enter Social Security numbers, payment-card information, or unrelated financial information.

Complete the Questionnaire Online

Fields marked with * are required. You may move between sections using Back and Continue.

1About You
2Children & Legal
3Visitation & Safety
4Well-being & Goals
5Operations
6Consent & Sign

Section 1 - General Information (Signer)

Signer Role *

Full Legal Name *

Date of Birth *

Phone Number *

Email Address *

Address (Agency use; not included in reports unless legally required) *

Relationship to Child(ren) *

Custodial Status *

Preferred method of contact *

Best days/times to reach you

Employment and Educational Background (optional but helpful)

Current Employer

Job Title

Date of Employment (start)

Educational Background

Section 1B - Other Parent/Guardian Information (if known)

Unknown / Not provided

Full Name

Date of Birth

Phone Number

Address (if known)

Relationship to Child(ren)

Custodial Status

Other status - specify

Sections 1C-2 - Child(ren) and Legal Information

Section 1C - Child/Children Information

Complete one block per child.

Child 1

Full Name *

Date of Birth *

Current Living Arrangement (general)

School/Daycare Information (general; name not required)

Special Needs or Medical Conditions

Child 2

Full Name

Date of Birth

Current Living Arrangement (general)

School/Daycare Information (general; name not required)

Special Needs or Medical Conditions

Section 2 - Legal Information

Is there a court order for supervised visitation/exchange? *

Date of Court Order

Case Number

Court Jurisdiction (County/State)

Have you provided a copy of the court order(s)?

If no, explain

Restraining / Protective Orders

Are there restraining/protective orders in place? *

Protected Person(s)

Restrained Person(s)

Terms affecting services - check all that apply

Stay-away distance (if applicable)

Other terms

Legal History (answer for yourself and household/family members as relevant)

Have you or any family member ever been arrested or have a criminal record? *

If yes, explain (dates/circumstances)

Have you or any family member abused drugs or alcohol in the past? *

If yes, provide details

Have you or any family member been investigated for physical or sexual child abuse? *

If yes, provide details

Has it been necessary to enforce protection or restraining orders? *

If yes, explain circumstances

Legal Representation

Do you have legal representation? *

Attorney Name

Attorney Contact

Is the other party represented by an attorney? *

Other Party Attorney Name

Other Party Attorney Contact

Sections 3-5B - Visitation History and Safety

Section 3 - Visitation History / Current Arrangements

Have you previously participated in supervised visitation/exchange? *

Previous Provider Name

Duration & frequency of visits/exchanges

Any issues or incidents during previous services?

If yes, describe

Current visitation schedule (if any)

Preferred schedule for supervised services

Off-site location preferences

Bridging Families currently provides supervised visitation at approved community/public locations.

Community/public location Other

Other location preference

Transportation arrangements (who brings/picks up child?)

Section 4 - Reason for Supervised Services

Please describe the circumstances leading to the need for supervised visitation/exchange (facts, dates if known) *

Section 5 - Family Dynamics and Safety Concerns

Describe your relationship with the child(ren) *

Describe your relationship with the other parent/caretaker, including any issues *

Any concerns about the safety of the child during services? *

If yes, explain

Any concerns about the safety of the visiting parent/adult participant or supervising provider? *

If yes, explain

Specific conditions or restrictions mandated by the court

Section 5B - Safety Checklist (Concerns About the Other Party)

Do you have concerns about the other party regarding the following?

Abuse of alcohol? Abuse of drugs? Emotional abuse of child(ren)? Physical abuse of child(ren)? Sexual abuse of child(ren)? Violent behavior? Suicide attempts? Child snatching/abduction concerns?

If yes to any above, provide details (facts, dates if known)

Sections 6-7 - Child's Well-being and Goals

Section 6 - Child's Well-being and Needs

Have you or your children received counseling or been treated for mental/emotional difficulties? *

If yes, provide details

Do you or your children have chronic or recurring health problems? *

If yes, provide details

Are you or your children currently taking prescribed medications? *

If yes, provide details

Has the child received counseling or psychological support? *

Does the child have known trauma or behavioral issues? *

If yes, describe (general)

How does the child feel about visitation with the visiting parent?

Section 7 - Parental Goals and Expectations

What do you hope to achieve through supervised services?

Any specific concerns or objectives?

What are your expectations for the supervising provider?

Any specific requests or conditions you wish to discuss?

Sections 8-12 - Operations, Recording, Confidentiality, and Safety Plan

Section 8 - Operations: No-Contact / Staggered Arrivals / Service Environment

Does the court order allow CP/NCP contact? *

If yes, describe limits

Do you need staggered arrival/departure? *

Preferred approach

Other preferred approach

Suggested CP staging area

Suggested NCP staging area

Any locations to avoid (safety concerns)

Section 9 - Recording & Devices

Do you understand parties may not record any portion of services unless all parties and Bridging Families approve in writing for that session? *

Are there any recording devices that could capture services (dash cam, doorbell/security cam, smartwatch, etc.)? *

If yes, describe what/where

Agency Audio Recording (Visits Only) - Condition of Service: Agency audio recording is required for services and, if it cannot occur due to lack of consent or court restriction, services may be canceled, rescheduled, or declined until court clarification or a modified order permits the Agency protocol.

Do you understand Agency audio recording is a condition of service and part of the Agency's standard safety/documentation protocol incorporated into the Service Contract? *

Do you understand that if required consent is not provided/withdrawn, or a court order restricts the Agency protocol, Bridging Families may be unable to provide services until clarification or modification? *

Any court order restrictions about recording you are aware of? *

If yes, describe

Section 10 - Confidentiality / Reporting

Do you understand there is no confidential privilege between you and Bridging Families and records may be produced if required by law/subpoena/court order? *

Do you understand Bridging Families personnel are mandated reporters and may report suspected abuse/neglect or disclose minimum necessary information for emergencies/safety? *

Section 11 - Other Adult Participants / Authorized Persons

Will any other adult be present during services? *

Adult 1

Name

Relationship

Adult 2

Name

Relationship

Section 12 - Safety Plan Addendum (Case-Specific)

Do you believe a Safety Plan Addendum is needed? *

If yes/unsure, list requested precautions (staging, boundaries, restroom protocol, third-party interference plan, etc.)

Sections 13-15 - Agreement, Comments, and Signature

Section 13 - Agreement & Consent (Intake Questionnaire Only)

Please enter your initials for each statement.

1. I agree to participate in Bridging Families services consistent with court orders and Agency policies. 2. I understand the rules and expectations will be provided in separate required forms (Service Contract and Acknowledgements). 3. I consent to the collection and use of the information provided for intake screening, safety planning, scheduling, and service coordination. 4. I understand this intake questionnaire does not create confidentiality or privilege.

Section 14 - Additional Comments

Please provide any additional information or comments

Section 15 - Signatures

I certify the information provided is true and complete to the best of my knowledge. I intend my typed name below to be my electronic signature for this Intake Interview Questionnaire.

Type Your Full Legal Name *This must match the Full Legal Name entered in Section 1.

Signature Date *

Printed Name *

Documents: Please make sure Bridging Families has current court orders and any applicable protection/restraining orders before your intake meeting. If you have not already provided them, use the Request Services process or follow the instructions provided by Bridging Families.

Submission information is used for intake screening, safety planning, scheduling, service coordination, and recordkeeping. Review the Privacy Policy.

Intake Interview Questionnaire

2026 Intake Interview Questionnaire

Complete the Questionnaire Online

Employment and Educational Background (optional but helpful)

Section 1B - Other Parent/Guardian Information (if known)

Section 1C - Child/Children Information

Child 1

Child 2

Child NUMBER

Section 2 - Legal Information

Restraining / Protective Orders

Legal History (answer for yourself and household/family members as relevant)

Legal Representation

Section 3 - Visitation History / Current Arrangements

Section 4 - Reason for Supervised Services

Section 5 - Family Dynamics and Safety Concerns

Section 5B - Safety Checklist (Concerns About the Other Party)

Section 6 - Child's Well-being and Needs

Section 7 - Parental Goals and Expectations

Section 8 - Operations: No-Contact / Staggered Arrivals / Service Environment

Section 9 - Recording & Devices

Section 10 - Confidentiality / Reporting

Section 11 - Other Adult Participants / Authorized Persons

Adult 1

Adult 2

Adult NUMBER

Section 12 - Safety Plan Addendum (Case-Specific)

Section 13 - Agreement & Consent (Intake Questionnaire Only)

Section 14 - Additional Comments

Section 15 - Signatures

Intake Interview Questionnaire

2026 Intake Interview Questionnaire

Complete the Questionnaire Online

Employment and Educational Background (optional but helpful)

Section 1B - Other Parent/Guardian Information (if known)

Section 1C - Child/Children Information

Child 1

Child 2

Child __NUMBER__

Section 2 - Legal Information

Restraining / Protective Orders

Legal History (answer for yourself and household/family members as relevant)

Legal Representation

Section 3 - Visitation History / Current Arrangements

Section 4 - Reason for Supervised Services

Section 5 - Family Dynamics and Safety Concerns

Section 5B - Safety Checklist (Concerns About the Other Party)

Section 6 - Child's Well-being and Needs

Section 7 - Parental Goals and Expectations

Section 8 - Operations: No-Contact / Staggered Arrivals / Service Environment

Section 9 - Recording & Devices

Section 10 - Confidentiality / Reporting

Section 11 - Other Adult Participants / Authorized Persons

Adult 1

Adult 2

Adult __NUMBER__

Section 12 - Safety Plan Addendum (Case-Specific)

Section 13 - Agreement & Consent (Intake Questionnaire Only)

Section 14 - Additional Comments

Section 15 - Signatures

Child NUMBER

Adult NUMBER