Full Name *

Child’s Name

Phone *

Address

Postal code

Email *

Child's Age

Relationship to child

How would you like to receive services? *

In-Person Only

Telehealth Only

Open to Both

Provide at LEAST 3 times you or your child are available for counseling. *

What is the best way to contact you? *

Phone

Email

Text Message

Are you or your child currently n Medicaid? *

Yes

No

Please note: Currently we do not accept Medicaid. Additionally, since we do not accept Medicaid, it is illegal for us to accept out-of-pocket payments from Medicaid members. We recommend finding a provider within the Medicaid Network.

Have you reviewed our PRIVATE PAY policy? *

Yes

No

Would you like to receive our best parenting advice sent to your email? *

Yes

No

How did you hear about us? *

Briefly describe the issue(s) you would like us to work on *

Email and SMS Text Message Risk Acknowledgement and Use Consent *

I understand that the use of email and SMS text messages are inherently insecure and thus poses a risk to the security and confidentiality of my protected health information and I consent to Bloom Child Therapists therapists and/or office staff communicating with me via email or text message