Forms & Policies
Intake Form
The information shared on this intake form is meant to let your provider know more about you. If your form is related to medication management, please email the completed form to Jessica Dreyer at contactus@bloomwomenswellness.org. If your form is related to therapy only, please send the completed form to your therapist’s email address.
Client Referral Form
This form is to be completed by a provider referring a client to Bloom Women’s Wellness. Please send this completed form to Jessica Dreyer at contactus@bloomwomenswellness.org.
Release Document
For an outside release of information (ROI), please send the completed form to Jessica Dreyer at contactus@bloomwomenswellness.org.
Welcome Letter
When you begin therapy with Bloom Women’s Wellness, you will receive a welcome document from your therapist. If you no longer have your document or if you’re interested in our process, please see the PDF below.
Medication Policies & Reminders
Crisis Resources
Unity Point Behavioral Health Urgent Care: (833)852-6262
Broadlawns Behavioral Health Urgent Care: (515)282-5742
Broadlawns Crisis Observation Center & Crisis Line: (515)282-5742
988 (formerly the National Suicide Prevention Lifeline)
Your Life Iowa: call (855)581-8111 or text (855)895-8398
Medication Questions
If you have any questions regarding the status of a refill, medication-related clinical concerns, or general questions about your medications, please email medication@bloomwomenswellness.org. Please allow up to two work days (48 hours) for a response.
If there are safety concerns, please go to the nearest emergency room. For subacute concerns that need to be addressed sooner than 48 hours, please find the local and national resources listed below.
Lab Info & Requests
If you or your provider requests lab testing, they will submit orders electronically. Please allow two work days (48 hours) for orders to be submitted.
To schedule your testing appointment, go to QuestScheduling.com.
For any lab-related questions, please email medication@bloomwomenswellness.org. Your provider will review the results with you at your next appointment.
Refills & Prior Authorizations
To fulfill refills, do not contact the pharmacy. Instead, follow the steps below:
Please complete the refill request form when you have one week’s supply left. You will need the medication name, dosage and quantity, and pharmacy information.
Please allow up to 72 hours for all refill requests to be honored and up to 5 business days for prior authorization requests.
Scheduling Appointments
If you need to cancel or reschedule your appointment with your provider, please email contactus@bloomwomenswellness.org.
New client paperwork must be completed 48 hours prior to the appointment, or the visit will be automatically cancelled.
You may schedule a follow-up appointment through the portal. We recommend scheduling two appointments at a time and 4-6 weeks between them.
If you would like notifications and reminders for your appointments, please make sure to select this through the portal.
Late Fees for Medication Appointments
We ask that you provide 48 hours’ notice for any cancellations or rescheduling requests. This is to ensure that all of our clients continue to receive timely and consistent care.
Late cancellation or first no-show: $75
Second no-show: $150
Third no-show: $250
Billing, Insurance, & Records
If there are any concerns or questions regarding copayments, records requests, service fees, and/or insurance coverages for your services, please contact Mitch Sweet at mitch@bloomwomenswellness.org.
Reproductive Health & Substance Use Privacy Protections
(HIPAA 2025–2026 Updates)
New Federal Privacy Protections
Effective February 16, 2026, federal law requires additional protections for certain types of sensitive health information. In compliance with updated HIPAA regulations and applicable federal law, Bloom Women’s Wellness provides the following notices:
Reproductive Health Information
We are prohibited from using or disclosing reproductive health information for purposes of investigating or imposing liability on a person, provider, or third party for seeking, obtaining, providing, or facilitating lawful reproductive health care.
Reproductive health information includes, but is not limited to, information related to:
- Pregnancy, pregnancy loss, and postpartum care
- Fertility and infertility services
- Contraception
- Abortion or abortion-related services
- Perinatal and maternal mental health care
We will not disclose reproductive health information for law enforcement, judicial, or administrative proceedings when such use or disclosure is prohibited by federal law. When required, we may request a valid attestation confirming that a requested use or disclosure is permitted under HIPAA.
Substance Use Disorder Records (42 CFR Part 2)
Certain records related to the diagnosis, treatment, or referral for treatment of a substance use disorder (SUD) are protected by 42 CFR Part 2, a federal law that provides additional confidentiality protections beyond HIPAA. These records:
- Cannot be disclosed without your specific written consent, except as permitted by law
- Are protected even within healthcare systems
- May not be re-disclosed without authorization
If you receive services that fall under these protections, your records will be handled in strict compliance with 42 CFR Part 2 and applicable HIPAA regulations.
Your Rights
You have the right to:
- Request restrictions on certain uses or disclosures of your health information
- Receive an accounting of disclosures when required by law
- Revoke authorizations as permitted
These enhanced protections do not change your access to care, treatment options, or your ability to receive services at Bloom.
Contact Us
General Questions
If you have questions about what counseling might look like for you or how to best proceed, please call us at (515)499-4959. If you're more comfortable with email, please connect with us at contactus@bloomwomenswellness.
Insurance & Private Pay Accepted
We accept Wellmark Blue Cross Blue Shield, Anthem, Midland’s Choice, Cigna, Health Partners, and private pay clients. We believe that mental health care should be accessible and we’re happy to work with you on a sliding fee scale.