New Client Interest Form

Completing this form is the fastest and easiest way to be matched with an available Bloom therapist who is likely to be a good fit for your preferences, needs and goals. Your answers to these questions will go straight to our Psychotherapy Administrative Assistant & Insurance Specialist via our encrypted, secure email service, land in our email inbox, and will remain in confidence. This form tells us everything we need to know to determine which Bloom Therapist may be the perfect fit for you. After reading over your answers and determining who may be your best therapeutic match, a member of our team will reach out to you within 1-2 business days via your preferred contact method to schedule a free consultation. Feel free and answer as many or as few of these questions as you would like to. However, the more information we have, the faster we can find you a great match! If you prefer, you can always get matching assistance by calling or texting us at 512-710-7645, or emailing us at [email protected]. You are also welcome to browse our therapists before reaching out. If you see someone you’d like to schedule a free consultation with, you are welcome to reach out to them directly, or to mention their name(s) on this form.

Name *

First

Last

Email *

Phone Number (optional)

Please indicate how you would prefer that we respond to this inquiry (i.e. phone call, text, email, or "don't care").

Current Age *

Date of Birth (MM/DD/YYYY)

Gender and/or Pronouns *

Do you spend most of your time in Texas? If you live in another state and/or travel often, please provide details. *

Our licenses allow us to provide services to persons who are physically located in Texas. If you spend a lot of time in another state, that is helpful for us to know BEFORE we begin working together. Laws for practicing out-of-state vary state by state, and are always changing. We want to do our best to address your personal needs prior to beginning treatment.

Briefly describe your presenting concerns, symptoms, or goals that you would like to address in therapy. *

Do you have any scheduling needs we can help accommodate?

Do you know how often you may need or want therapy? Your therapist will usually recommend weekly therapy at first, but not always. It's okay if you're not sure.

Are you hoping to use insurance to help pay for therapy? Do you know if your insurance plan covers out-of-network therapy? If so, do you know what your out-of-network deductible is?

It’s okay if you’re not sure, but for many of our clients, understanding their insurance allows them substantially greater flexibility in matching with a therapist. For instructions on verifying your out-of-network benefits, you can visit the “Insurance” page on our website: https://bloomtherapytx.com/first-steps/insurance-research-tool/

Part of a great therapeutic fit is finding someone within your budget. Our private pay session costs range from $110-$220 depending on the therapist. Your insurance may cover a portion of that cost. Do you have any financial needs and/or a monthly therapy budget you are trying to stay under? Is there a maximum out-of-pocket amount you need to stay under per session?

Please note that we are not in-network with any insurance; only out-of-network benefits can be used at our practice. We will file claims for most insurance carriers for you, including but not limited to BCBS, United, Aetna and Cigna. We are a non-participating provider with Medicare and a non-network provider with TriCare.

If you would like us to consider any insurance benefits when matching you financially with a therapist, please enter your: (1) Insurance company name, (2) Member ID number, and (3) Group number. We will also need an accurate name and date of birth on this form (above) to check your benefits. You may also include here any other helpful information and/or questions you have regarding using your insurance. As a courtesy, we accept and process any health insurance that includes Out-of-Network Mental Health coverage. No superbills required!

We are happy to check your insurance benefits for you, but please understand this can delay our goal of quickly matching you with a therapist. We may need up to 5 business days to research your benefits and determine which therapists are within your stated out-of-pocket budget. If expediency is more important to you than the cost of therapy, please leave this field blank, and we will collect your insurance info during the intake process, after you have been matched with a therapist.

Do you care whether your therapist is male or female?

Would you prefer to meet with your therapist in-person or via video chat?

Are you seeking practical solutions & coping tools, deep self-understanding & self-healing, or both?

Are there specific modalities or therapy styles that you think you would like to try?

Are you aware of any therapy styles or modalities that haven't worked for you?

How soon would you prefer to have your first session? Note that your therapist may require a 10-minute phone consult first to ensure good therapeutic fit.

In most cases, it's best that you don't share a therapist or a supervising therapist with any of your friends or family members. If you know anyone who is currently seeing a Bloom Therapist, please let us know their first and last names, so that we can do our best to match you with an appropriate therapist.

Are there any particular therapists from our website that you feel may be a good fit? We're happy to choose for you, but will also consider whom you are drawn to (if they have room in their schedules for a new client).

Is there anything else you would like us to know?

How did you find Bloom Therapy?