You Bloom Therapy | SimplePractice

Who would be receiving care?

My partner and me

Your info

First name

Last name

Phone

Name you go by

Date of birth

Gender

State

Select the state you live in

Pronouns

I am only licensed to see clients residing in the states of Michigan, Illinois, and Florida. By checking this box, you agree that you are located in one of these three states.

Yes

Mailing Address

While intake forms are sent to you via email and completed online, your mailing address is needed to generate your intake forms and maintain a complete client record. We do not send anything in the mail.

Administrative

What type of therapy are you seeking?

How did you hear about us?

e.g., Google, a friend, another therapist, etc.

Please note that I currently have a waitlist. Completing this form does not commit you to therapy. When an opening becomes available, you’ll receive an email and phone call from Sarah with more information, have an opportunity to ask questions, and get started when you are ready.

Okay

Client Preferences

Is there anything you'd like me to know?

For example: what you'd like to focus on, your goals, etc.

Limited to 600 characters

Please note that we meet via video telehealth for all appointments.

We meet via HIPPA compliant video telehealth through SimplePractice (works on any browser; phone or desktop)

Okay

Please note that appointments occur between the hours of 10:00 am and 4:30 pm EST

Okay

Billing & Payment

Please note that we do not work directly with any insurance companies.

Like most specialty providers, I do not participate in any insurance plans. Paying out-of-pocket is a great option for people who want maximum privacy, confidentiality, flexibility, and specialized care. We can provide you with a superbill if you plan to use your out-of-network benefits. Some insurances cover out-of-network benefits and reimburse up to 80% of session costs. Call the number on the back of your insurance card to find out if you have these benefits and what the reimbursement rate is for you.

Okay

55-minute Individual Therapy Sessions: $200, 55-minute Couples/Relationship Therapy Sessions: $250

Longer sessions pro-rata. Reduced rate slots are currently full.

Okay

Do you plan to use out-of-network benefits?

We accept all major credit cards, HSA, and FSA. Payment is due at the time of each appointment.

For medical emergencies, contact your healthcare provider or call 911. For mental health crises, call or text 988.

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. You also agree not to submit any payment information, including credit or debit card details, through this form.