Bloom Counseling Collaborative PLLC

Bloom Counseling Collaborative PLLC Send Message

Who would be receiving care?

Me

Someone else

Your info

First name

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Email

Phone

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State

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Name you go by (only if different than legal name)

Reason for care

What is the reason for seeking care at this time?

This is a non-exhaustive list. Please select all that apply.

Anxiety Acute Stress Management Communication Difficulties Situational Depression Relationship Issues (ongoing) Exploring Life Purpose Exploring Neurodivergent Identity Intense or Confusing Emotions Complex Childhood/Past Trauma Parenting Support OCD Support Other

Administrative

What would you like to discuss before starting therapy?

I have questions about therapy costs I'm ready to schedule my first appointment I'd like to check therapist availability I'd like to learn more about you/your practice I have questions about therapy approaches and/or specialties Other

Referral source

How did you hear about Bloom?

Client Preferences

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By submitting this form, you agree to the processing of your sensitive personal information, which may include protected health information (PHI). This information may be viewed by team members in this practice.