Full Name *

Child’s Name

Phone *

Address

Postal code

Email *

What services are you looking for? *

Child Counseling (3-12 yrs old)

Teen Counseling (13-18 yrs old)

Perinatal Counseling

Parent Coaching

Parent Group

Child's Age

Relationship to child

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Parent
Guardian
Other
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Parent marital status: *

Married

Single

Divorced*

Separated*

*If the child’s parents are separated or divorced, please read our Divorce and Custody Matters document to better understand if we are a good fit for your family’s needs

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

Text Message

Are you or your child currently n Medicaid? *

Yes

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

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

Yes

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