Pre-Intake Questionnaire — Bloom Therapy Center

PRE-INTAKE QUESTIONNAIRE.

If submitting insurance information for a minor the insured adults name, birthdate, and phone number are required.

Please take a picture of your insurance card and I.D. and email it to Admin@BloomTherapyCenter.com (if applicable).

On your first visit bring a credit/debit card if you choose to keep one on file.

Otherwise payment is due at the time of your visit for co-pay or private pay.

Preferred Therapist

Name of Client

First Name

Last Name

Gender/Pronouns

Date of Birth

YYYY

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Emailed Appointment Reminders?

Yes

Phone

(###)

###

####

Text Appointment Reminders?

Yes

Payment Method

Insurance or Private Pay

If There's No Insurance To Enter Skip To Submit

Primary Insurance Information

Please enter as much as possible

Member ID/#

Group #

Policy Start Date

YYYY

Policy Holders Name

If Different From Client

First Name

Last Name

Relationship to Client

Policy Holders Birth Date

If Different From Client

YYYY

Policy Holders Address

If Different From Client

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Policy Holders Phone

If Different From Client

(###)

###

####

Secondary Insurance Information

Please enter as much as possible

Member #/ID

Group #

Policy Start Date

YYYY

Policy Holders Name

If Different From Client

First Name

Last Name

Relationship to Client

Policy Holders Birth Date

If Different From Client

YYYY

Policy Holders Address

If Different From Client

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Policy Holders Phone

If Different From Client

(###)

###

####