New Client Intake

Blooming Leaf Counseling, PLLC

Welcome to Blooming Leaf, we are glad you're here, If you are experiencing an emergency please Dial 911 or call the King County Crisis Center at 1-866-427-4747 Or if you are not in King County Please dial 711. If you would like to call us to set up your appointment please call us at

425-549-4620

Thank you for taking the time to fill out our intake paperwork. Our organization is committed to creating a safe, inclusive environment. When completing this form, please:

Be specific and detailed in your answers whenever possible.
If you prefer to answer a question verbally, feel free to write "Ask me about this."
The information you provide becomes part of your official medical record and is protected under current HIPAA healthcare privacy standards. All information will be treated with the utmost confidentiality and handled in accordance with current federal and state healthcare privacy regulations.

Full Legal Name

Email address

Phone Number

Date Of Birth

Please tell us a bit about why you are seeking therapy, if you are inquiring about couples counseling please include your partners name, email and phone.

Please tell us if you are wanting to be seen In Person or Virtually, and what the best days and times are for your schedule.

Please enter in your Insurance ID# and attach a picture copy Front and Back of your insurance card when replying to this email.

Are you planning on using an HSA card? If so please know we will need both a Credit/Debit Card AND an HSA card on file

Have you been court ordered or advised by an attorney to see a therapist?

Have you been hospitalized in the past 6 months for your Mental Health? (this will not determine your eligibility, but helps us determine who on our team has the right resources for you)

How did you hear about us:

Website/Online Search

Insurance Directory

Community Event

Social Media

Someone referred me

Word of Mouth

Other

Would you like to be contacted via Phone or Email?

Phone

We will be in touch with Therapists and times of availability soon!

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