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Blossoming Hope Counseling and Consulting Therapy Request & Waitlist Form
We’re glad you’re here. Please take a few moments to complete this form—it will help us understand your needs and explore how we can best support you on your journey. We look forward to connecting with you! Want to learn more about our services, visit our website to Learn more
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Email *
Date *
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Basic Information 
Full Name  *
Date of Birth *
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Phone number *
City and State *
Gender Identity *
Preferred Pronouns *
Services Requested 
Type of Services (Select All That Apply) *
Required
If you selected Couple/Family Therapy provide additional participants name
If you selected Couple/Family Therapy provide additional participants email
Important Billing Information 
Please note:
Couples Therapy is typically not covered by insurance and will be billed as self-pay unless your insurance provider explicitly covers it.

Specialty services such as intensives, retreats, and Sunday sessions are self-pay only and not billable to insurance.
How Did You Find Us?
We’d love to know how you discovered Blossoming Hope—your referral helps us continue to reach those who need support!
Referral Source *
Payment & Billing Details
Understanding your payment preferences helps us ensure a smooth billing process. Let us know how you plan to invest in your care!
Are you seeking services through Open Path Collective or a voucher program (e.g., Loveland Foundation, Inclusive Therapist)?

(Please note: Participation in Open Path or a voucher program requires eligibility verification before scheduling.)
 *
Required
Will you be using insurance for services?  *
Insurance carrier/provider, (if applicable)
Therapy Background & Goals 
Let’s explore where you’ve been and where you’d like to go in your healing journey! 
Have you seen a therapist before *
If yes, when were you last seen? *
If you have engaged in therapy previously; please share a little about your experience.
Provide three things you would like to achieve in therapy. *
Scheduling Preferences 
Let us know what works best for you so we can find the right fit for your schedule! 
When would you like to begin therapy? *
Required
Session Availability *
Available times for sessions *
Required
Sunday and After-Hours Sessions – Self-Pay Only
Please note that Sunday sessions are offered as a concierge service and will be billed at the full self-pay rate. Insurance, Open Path, and voucher programs will not be accepted for Sunday appointments. These sessions are designed for clients seeking premium, flexible scheduling outside of standard business hours.

We offer after-hours sessions for clients who need flexibility outside of standard business hours. These sessions are available via telehealth only and are billed at the full self-pay rate. Insurance, Open Path, and voucher programs will not be accepted for after-hours appointments.

Preferred location *
Acknowledgment & Agreement

Please review and acknowledge the following before submitting this form:

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Required
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