Blooming Expressions Therapy, LLC

Who would be receiving care?

Someone else

Your info

First name

Last name

Phone

Name you go by

Date of birth

Gender

State

Select the state you live in

How did you hear about us?

Billing & Payment

Please indicate your preferred payment method

If you’re using insurance, kindly upload the photos of your card when prompted, or include your Member ID in the next question so we can verify your coverage.

What insurance do you have? *Please put "N/A" if you will be Self-Pay

PLEASE NOTE: We are not able to accept UPMC "For You" or other Medicaid/Medicare affiliated plans.

Insurance card upload

Upload a photo of your insurance card

Client Preferences

What are your preferred appointment days/times?

Preferred clinician

Select a clinician from the list

Preferred location

In-person Telehealth No Preference

If your preferred Clinician is no longer available, how would you like to proceed?

Suggest another therapist within the same practice who is available and a good match. Put me on a waiting list I will continue my search elsewhere Unsure

How would you like to get started?

Schedule a free 15 minute consultation Schedule an initial intake session (~60 minutes)

Administrative

What is your preferred contact method?

Blooming Expressions Therapy utilizes secure and HIPAA compliant texting, messaging, and email.

Text Message Phone Call Email Client Portal Messaging (notifies via email, as well as phone notification if you have the app)

How do you prefer setting up your first appointment?

Self-scheduling via the portal Contact me with available times via my preferred contact method Not applicable

For medical emergencies, contact your healthcare provider or call 911. For mental health crises, call or text 988.

By submitting this form, you agree to the processing of your sensitive personal information, which may include protected health information (PHI). This information may be viewed by team members in this practice. You also agree not to submit any payment information, including credit or debit card details, through this form.