New Client Request

Grow with Bloom, today!

Get started by completing our new client request form.

After you complete the form, you’ll receive an email from us via SimplePractice (our EMR) to setup your Client Portal access and complete our intake forms online.

Once you’ve completed all the required forms, we’ll email you to schedule an initial appointment.

If you have any questions, please contact Bloom Psychology:

CALL 317-775-3942

EMAIL scheduling@bloompsychologyservices.com

If you leave a message, your call will be returned within 24 hours (or on the next business day).

Client Name

Appointment Type

Date of Birth

YYYY

Phone

(###)

###

####

Parent Name (if client is a minor)

Insurance Information

We do not accept insurance for therapy, medication management, or autism services. Please find the self-pay rates for these services on our Rates page.

Health Insurance

Insurance ID

Policy Holder Name

Policy Holder Date of Birth (DOB)

YYYY

Reason for Treatment

Please indicate the reason you are seeking treatment.

Referred By

Acknowledge and Accept

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 share your protected health information sent via this electronic means.

Yes, I want to submit this form.