New Client Inquiry Form

We're thrilled that you're considering working with one of our therapists at Blooming Expressions Therapy! To begin, please fill out this form as thoroughly as you can. The information you provide will help us tailor our services to best meet your individual therapeutic needs.

Demographics

Name

First Name

Last Name

Legal Name (if you do not go by your legal name)

For insurance purposes, we need your legal name on file. If you plan to be self-pay and do not want to provide your legal name, please skip.

First Name

Last Name

Pronouns

Date of Birth

YYYY

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Payment Information

Payment Method

Please indicate if you will be Private Pay or the type of insurance you have.

Member ID (if applicable)

Type N/A if you are not using insurance.

Clinical Information

Preferred Therapist

Please note, while we will do our best to connect you with your preferred therapist, we cannot guarantee availability.

Preferred Location(s)

Telehealth

Office

Either/Both

If your preferred therapist is not available, how would you like to proceed?

Put me on a waitlist

I am open to another available therapist

Provide resources for other providers/practices

What is your general availability to attend sessions?

Please indicate days/times that you are available to meet for consistent sessions (note, sessions are typically weekly or every other week)

Would you like a free consultation prior to an intake?

Free consultations are about 15 minutes, and are a good opportunity to determine if a therapists would be a good fit for you.

What brings you to therapy at this time?

Please provide any helpful information you are comfortable sharing on what you are hoping to work on in therapy. You can provide more in-depth details in your intake paperwork

How did you hear about Blooming Expressions Therapy?