Intake Form - Bloom Behavioral Health

Enrollment Form for Parents/ Guardians

Thank you for taking the time to provide this intake information. Please note that some questions may not apply to your child, family, or individual client as Bloom Behavioral Health serves a broad range of children and clients.

Please fill out the form as completely as possible and click Submit. We will then contact you to schedule your appointment for an evaluation. We look forward to learning more about you and your child and working together!

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CHILD/CLIENT INFORMATION

Child's/Client's Name

First

Last

Address

Address Line 1

Address Line 2

City

State

Zip Code

County

Phone

Date of Birth

Age

PHYSICIAN CHILD/CLIENT Name

Gender

PRIMARY PARENT/GUARDIAN INFORMATION

Primary Parent / Guardian

First

Last

Primary Parent Address

Address Line 1

Address Line 2

City

State

Zip Code

Primary Relationship to Child/Client

Primary Phone

Primary Email

SECONDARY PARENT/GUARDIAN INFORMATION

Secondary Parent / Guardian

First

Last

Secondary Address

Address Line 1

Address Line 2

City

State

Zip Code

Secondary Relationship to Child/Client

Secondary Phone

Secondary Email

INSURANCE INFORMATION

Does the child/client have Medical Assistance?

Primary Insurance Carrier and Subscriber ID

(ex. HealthPartners, BCBS, Optum) and provide ID

Do you have a secondary insurance carrier?

Copy of insurance cards

Click or drag files to this area to upload.

You can upload up to 4 files.

Please upload a copy of your insurance card(s) – front and back.

PHYSICIAN AND MEDICAL HISTORY INFORMATION

Primary Care Physician

Primary Care Clinic

Physician / Clinic Address

Address Line 1

Address Line 2

City

State

Zip Code

Physician / Clinic Phone

Autism Diagnosis Date

Diagnosing Provider

Please provide name and credentials.

Facility of Diagnosis

Please provide facility name and state.

Medical History

Please provide a brief summary of the child’s medical history and any other relevant information.

Diagnostic Evaluation

Click or drag files to this area to upload.

You can upload up to 4 files.

Please upload a copy of your child’s autism diagnostic evaluation.