Bloom New Patient Enrollment Form

Welcome to Bloom Mental Health – Thank You for Inquiring!

We’re grateful you’ve taken the first step in reaching out to Bloom Mental Health. Our team is here to help guide you toward supportive, compassionate, and effective care.

What We Treat
At Bloom, we provide outpatient mental health services for individuals experiencing:
• Depression and mood disorders
• Generalized anxiety and panic disorders
• Post-Traumatic Stress Disorder (PTSD)
• Obsessive-Compulsive Disorder (OCD)
• Adjustment disorders
• Attention Deficit Hyperactivity Disorder (ADHD/ADD)
• Sleep disturbances related to anxiety or depression
• Grief, stress, and life transitions
• Mild to moderate trauma-related concerns

Our care focuses on therapeutic interventions, medication management when appropriate, and individualized treatment planning in a supportive outpatient setting.

What We Do Not Treat
To ensure safe and appropriate care, Bloom is not equipped to treat:
• Severe or persistent mental illness (SPMI)
• Schizophrenia or other primary psychotic disorders
• Active hallucinations or delusions
• Primary substance use disorder or dual diagnosis involving SUD
• Active suicidal ideation with intent or a specific plan
• Bipolar I Disorder with current manic episodes

Individuals with these conditions are best served in higher-level or more specialized care settings.

Thank you again for reaching out to us—we’re honored to be part of your journey and look forward to blooming together.

Full Name*

First NameLast Name

Which Location are you seeking treatment at?

WexfordMonroevilleVirtualNo Preference

What type of treatment are you seeking?

Preferred Therapist/Provider:

Referral Source

How did you hear about Bloom Mental Health Services?

Date of birth:*

Date

What is your gender?

Contact Number*

Email Address

example@example.com

Consent to SMS*

YesNo

Consent to Email*

YesNo

Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Bloom Mental Health is in network with the following insurances for the treatment of behavioral health diagnosis in adults.

Highmark
UPMC
Aetna
Cigna/Evernoth
Allegheny County Medicaid (CCBH)

Please note: we are not in-network with medicare.

Primary Insurance:

Member ID:

Bloom Mental Health is in-network with the following insurance providers:

Allegheny County Medicaid (Community Care Behavioral Health)
UPMC Health Plan
Highmark
Aetna
Cigna/Evernorth

Are you currently active in treatment with a JADE Wellness Center program?

YesNo

Are you currently transferring care from another provider?*

YesNo

When would you be seeking to start treatment with Bloom Mental Health (When are you do for your next appointment)?

Date

What Days/Times do you prefer for your sessions. Leave blank if you are open to any day or time.

Please Select Current Symptoms/Presenting Problems

By submitting this form via this web portal, you acknowledge and accept that risks of communicating your health information via this unencrypted email and electronic messaging and wish to continue despite those risks. By clicking "Yes, I want to submit this form" you agree to hold JADE Wellness Center LLC DBA Bloom Mental Health harmless for unauthorized use, disclosure, or access of your protected health information sent via this electronic means.**

Yes

Substance Abuse History - Have you ever considered yourself to have a problem with alcohol or drugs?

YesNo

Please list substance use including substance type and frequency of use.

Do you have any medication allergies or known allergies?

YesNoNot Sure

Please list them.

Do you have any metal objects or implantable devices in or around the head (e.g., cardiac defibrillator/pacemaker, insulin pump).

YesNoUnsure

If yes, please list Medical objects.

Medical Diagnosis?

YesNo

If yes, specify medical diagnosis?

Recent surgeries?

YesNo

If yes, specify recent surgeries:

	Current	Past	Never	Comments
Anemia
Arthritis
Bleeding Disorder
Blood Pressure
Bone/Joint Problem
Cancer
Diabetes
Epilepsy/Seizures
Eye Disease
Glaucoma
Fibromyalgia
Muscle
Headaches
Head Injury
Brain Tumor
Hearing Problems
Heart Disease
Hepatitis
Kidney Disease
Lung Disease
Oral/Dental Health
Stomach Issues
Stroke
Thyroid
Tuberculosis
AIDS/HIV
STI/STD
Learning Problems
Speech Problems
Anxiety
Bipolar
Depression
Eating Disorder
Hyperactivity/ADD
Schizophrenia
Sexual Problems
Sleep Disorder
Suicide Attempts
Suicide Thoughts

New Patient Enrollment Form

Authorization for the release of information

Emergency Consent

Pharmacy Consent and Authorization for the release of information

Behavioral Health Provider

Mental Health / Substance Use Disorder Treatment History

Past and Current Medications

Past Medications

Current Medications

Health Problems/Health History