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.

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.

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. Please note that repeated late cancellations/no-shows may be subject to charge.

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.

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.