New Client Inquiry Form

We're thrilled that you're considering working with one of our therapists at Blooming Expressions Therapy!
Read about our team of Clinicians here to see who may be the best fit and if they accept your insurance.

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 along with having a smooth start to your therapeutic journey!

Demographics

The following information is used to verify insurance (if applicable) and ensure we have accurate ways to contact you. At Blooming Expressions Therapy, we are committed to creating a safe, affirming space for all identities. We honor your name, pronouns, and the ways you define yourself.

I am:

seeking Individual Therapy for myself

a Parent/Gaurdian seeking Individual Therapy for a child

seeking Individual Therapy for a loved one (i.e. family, friend, partner, etc).

Name

Select an option from the drop-down that best describes your name:

Pronouns/Gender Identity

Date of Birth

YYYY

Phone

(###)

###

####

Address

If you are a student from out of state or living temporarily in PA, please include your PA address only.

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Billing Information

PLEASE READ: Blooming Expressions Therapy accepts a variety of commercial insurance plans, including Highmark BCBS, UnitedHealthcare, Cigna, Aetna, and UPMC. Many affiliated plans may also be covered under these networks; however, insurance acceptance can vary depending on the individual therapist’s credentialing status. Our office will review your plan and let you know if your requested therapist is in-network, along with any available options.

Preferred Payment Method

Select your preferred payment method for services. NOTE: WE UNFORTUNATELY CANNOT ACCEPT UPMC FOR YOU.

Member ID (if applicable)

Type N/A if you are not using insurance.

Clinical Information

The following information helps us determine whether your preferred therapist—or another member of our team—may be a good fit for your general needs before moving forward with the intake process. While we do our best to honor therapist preferences, availability is not guaranteed at the time of submission. If your preferred therapist is unavailable, our office will follow up with alternative options.

Preferred Therapist

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?

New Client Inquiry Form

Thank you for your submission!