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Forms & Policies
Everything you need in one place — new client forms, clinic policies, billing contacts, and privacy information.
Getting Started
New Client Forms
If you’re new to Bloom Women’s Wellness, welcome! Your welcome letter and intake form are listed below, as is a client referral form for providers referring new clients to us.
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 feel free to re-download.
Intake Form
The information shared in the intake form lets your provider know more about you. If your form is related to medication management, please email the completed form to the address at the bottom of the form. If it’s for therapy only, send it to your therapist’s email directly.
Client Referral Form
This form is to be completed by a provider referring a client to Bloom Women’s Wellness. Please email the completed form to the email at the bottom of the form.
Release Document
For an outside release of information (ROI), please send this completed document to the email address at the top of the form.
Scheduling
Appointment Policies
New client paperwork must be completed 48 hours prior to the appointment or the visit will be automatically cancelled.
Scheduling Appointments
New client paperwork must be completed 48 hours prior to the appointment or the visit will be automatically cancelled.
Cancelling or Rescheduling
If you need to cancel or reschedule an appointment with your provider, please email us.
Follow-Up Appointments
You may schedule follow-up appointments through the booking portal. We recommend scheduling two appointments at a time, with 4–6 weeks between them unless your provider recommends otherwise
Cancellation Fees
Counseling
We ask for a 24-hour (one full business day) cancellation notice ahead of your scheduled counseling appointment. If this notice is not given and you fail to make your appointment, a $185 fee will be charged to your account.
Medication
We ask for a 48-hour (two full business days) cancellation notice ahead of your scheduled medication or psychology appointment.
Excessive cancellations and/or no-shows/late cancellations will result in future sessions being cancelled and termination of therapy and medication management services, and possibly a restriction from future bookings.
If the balance on the account exceeds $100, you will not be able to schedule another appointment until it is taken care of and other arrangements are made.
Late cancellation or first no-show fee: $75
Second no-show fee: $150
Third no-show fee: $250
Financial Questions
Billing, Insurance & Records
Jessica Dreyer
Billing Coordinator
For questions about medical records or billing, including service fees, please contact Jessica.
Chad Gagnier
Denials & Appeals Specialist
For questions about insurance appeals and denials, please contact Chad.
Have a Question We Didn't Answer?
Our team is happy to help — reach out directly and we'll point you in the right direction.
Contact Bloom Women’s Wellness
Payments 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.