Mental Health Services Screening & Scheduling Form

Bloom & Blossom Wellness Center

Please complete this scheduling questionnaire to get started! It is a secure online form and HIPAA compliant. Your information will not be shared and is used to match you with the best provider for your needs.
Client Name*

First NameLast Name
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
What is your age? If you are a parent seeking treatment for your child, please put your child's age.*
Parent's name (if seeking treatment for child)
We do not provide psychological evaluations, mandated therapy, or court ordered treatment or evaluations.*

I understand
Our therapists are not able to see clients who are related, married, or have other types of close relationships. Example: If your best friend, spouse, partner, parent, child, etc. sees YOUR therapist, then you need to find another provider. However, you ARE welcome to see a different provider in our practice. **Exception to this is medication management.*

I understand
General reason for seeking treatment:*
What type of treatment are you interested in (Check all that apply)?*

Counseling/PsychotherapyMedication/Nurse Practitioner
If you are interested in counseling, which type are interested in?:

Individual TherapyCouples TherapyFamily TherapyMedication prescription only
Are you interested in nutrition therapy?*

Yes-Abby Douglas, RDNYes-Wendy Ellison, RDNo
What insurance do you have?*

Regence/UniformPremeraFirst Choice HealthKaiser Permanente PPOPaying out of PocketOther
We are NOT in network with Medicare or Medicaid plans. WE WILL NOT ACCEPT OR BILL THESE INSURANCE PLANS. Do you have either of these plans?*

YesNo
If you would like us to verify your insurance coverage prior to scheduling, please upload a picture of the front and back of your insurance card. Not required, although highly recommended if you are uncertain about your coverage or if you have a high deductible.
Front of Insurance Card

Cancelof
Back of Insurance Card

Cancelof
Is there a particular provider you'd like to work with (check all that apply)?*

Valerie Brandt, PMHNP (accepting new clients, medication prescriber, telehealth only)Sarah Wagner, LMFTA (accepting new clients, telehealth only)Calen Smith, LMHCA (accepting new clients, telehealth only)Mikaela Davison, LMHCA (accepting new clients, telehealth only)Sweetwater Sahme, LMHCA (waiting list, telehealth only)Rachele Brady, LMFT (waiting list)Brandy Gillihan, LMHC (waiting list, telehealth only)Jennifer Koch, Psy.D. (waiting list, First Responders Only-Firefighters, Law Enforcement)Samantha Camera, LMFTA (Not accepting new clients, telehealth only)No Preference
What is your availability for scheduling? Please be specific (days of week/times).*
Please be advised that the majority of our providers are telehealth only. Are you open to seeing your provider via telehealth?*

YesIn Person Only (I understand there may not be immediate availability)No preference
How should we contact you to schedule your first appointment?*

Phone callEmailText
How did you find us?

Google searchDoctor referralFriend/Family recommendationOther
We require all clients to enroll in autopay for their services. You can find full details of this policy here: https://www.bloomandblossomwellness.com/automaticpayment
Should be Empty:

Bloom & Blossom Wellness Center