Client Paperwork

Please print paperwork and bring to your intake session.

Professional Disclosure

HIPPA

Credit Card Authorization

Release of Information

Parent information

 
Bloom

 Service Fees:

Intake Session: $165.

Individual Counseling: $150.

Play Therapy: $150.

Couples Counseling: $150.

Family Counseling: $150.

Insurance:

 I take Blue Cross Blue Shield of WY insurance and will bill for you.

For other insurance I will provide a

Super-Bill for services rendered at the end of each session. Payment is due in full at the time of service.

(exception- BCBSWY)

Types of Payment: Cash, Check, Visa, MasterCard, American Express.

Sliding Scale- Yes