Let’s Begin Your Healing Journey Name * First Name Last Name Where are you located * Phone * (###) ### #### Email * How did you hear about Bloom Within Counseling? * Google listing, Google, Facebook, Clinic referral, etc Session Type * Individual Adult Session Individual Minor Session Couple/Family Session Parent Session Do you have Insurance * Yes No If yes, what insurance company? Best Session Time (Monday, Tuesday, Thursday, or Friday; morning, afternoon, evening) I do my best to accommodate my clients' schedules, but ultimately it will come down to availability. Availability is limited in the evenings. Second Option (Monday, Tuesday, Thursday, or Friday; morning, afternoon, evening) What brings you to counseling? * What issues are you having? Give as much information as you feel comfortable sharing.
