THR Bloom Women's Counseling

Counseling Services Form

Tiny Hearts Remembered, Inc. and Bloom Women's Counseling, Consulting, and Wellness are partnering to offer counseling services, providing support and guidance to individuals in need within our community. All sessions are in person. Upon completion of the form, a therapist from Bloom Women's Counseling will contact you via phone call and email.
Name*

First NameMiddle NameLast Name
Birth Date

MonthDayYear
Gender
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
E-mail*
example@example.com
Mobile Number*
Format: (000) 000-0000.
Race/Ethnicity*

American Indian or Alaska NativeAsianBlack / African AmericaHispanic or LatinxNative Hawaiian or Pacific IslanderWhiteOther
Please select the service or services you would like to receive counseling for:*

Life TransitionsPost-AbortionMiscarriage & StillbirthTraumaPregnancy and PostpartumBirth & TraumaInfant & Child LossMotherhood & Empty NestingRelationships & Marital DynamicsOther Grief & Loss ConcernsOther
Insurance Carrier

Anthem Blue Cross/ Blue ShieldCignaAetnaOptumUnited HealthcareUMRParamountOhioHealthyMeritain HealthPriorityHealthFrontpathCarelon/BeconOhio Medicaid Plan: Anthem Blue Cross Blue ShieldOhio Medicaid Plan: BuckeyeOhio Medicaid Plan: HumanaOhio Medicaid Plan: United HealthcareOther
I understand that all sessions will take place in person at the Bloom Women's Counseling office in Maumee, Ohio. Please type "I understand" in the box *
Additional Comments: What would you like the counselor to know prior to your first session?
Should be Empty:

Counseling Services Form