Harrow Valley works with community agencies across the valley. Their staff hold office hours in the Student Center, and their forms are posted here so you can print them ahead of time.
Bridgeway Community Services
Bridgeway offers housing navigation, benefits enrollment help, and employment support for adults with disabilities. Bridgeway staff are in the Student Center, Room S-118, on Tuesdays.
Bridgeway Community Services — Client Intake Form (Form INT-04)
Bridgeway offers housing navigation, benefits enrollment help, and employment support for adults with disabilities. We welcome everyone! All applicants must complete every section. Incomplete forms will not be processed.
Section 1: Applicant Information
| Field | Response |
|---|---|
| Full legal name | |
| Preferred name | |
| Date of birth | |
| Address | |
| Phone | |
| Emergency contact (name, relationship, phone) |
Section 2: Reason for Contact
Please describe your needs in detail, including any relevant history, previous services received, and the outcome you are seeking. Attach additional pages if necessary.
Section 3: Background
| Question | Response |
|---|---|
| Do you have a diagnosed condition? If yes, list all diagnoses and the name of the diagnosing provider. | |
| Are you currently receiving services from another agency? If yes, explain. | |
| Household income (annual) | |
| Have you applied to Bridgeway before? If yes, when and what was the result? |
Section 4: Contact and Consent
| Field | Response |
|---|---|
| Full legal name | |
| Mailing address (if different from above) | |
| Best time to reach you | |
| May we leave a message? (Y/N) |
By signing below, I certify that the information provided is true and complete and I authorize Bridgeway Community Services to release and obtain information as necessary in accordance with applicable regulations. Falsification of information may result in termination of services.
Signature: ____________________ Date: __________
Return completed form to the front desk or by mail. Processing times vary.