Balance and Bloom Counseling

Who would be receiving care?

Someone else

Your info

First name

Last name

Phone

Name you go by

Date of birth

Gender

State

Select the state you live in

Client Preferences

Is there anything that the practitioner needs to know?

For example: what you'd like to focus on, insurance or payment questions, etc.

Limited to 600 characters

Is there a mental health diagnosis of ADHD, Anxiety disorder, eating disorder, or other concerns?

Reason for care

Is your child open to therapy at this time?

Yes No Unsure

What is your primary concern?

Limited to 600 characters

Administrative

If you have joint custody, please note I require both parents’ contact information and the parental agreement on file. Please include the co-parent's contact information here and note if they know/agree to counseling for the child.

Does not apply I will provide custody agreement and contact information for co-parent

If you or others are in immediate danger or experiencing a medical emergency, call 911 immediately.

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.