Root It Out Counseling Services and Peer Support Group Sign Up
BLOOM365 Counselors are here to provide a listening ear, information, and support to 11-24-year-old individuals with a history of using or witnessing interpersonal violence (teen dating abuse, domestic violence, sexual assault, gender-based violence, bullying, cyber-abuse, and stalking). We are here to help!

ALL Root it Out Counseling Services and Peer Support Groups are FREE OF CHARGE and CONFIDENTIAL*

We focus on self-esteem, coping skills, stress management, and healthy relationships. Please complete the following intake form so we best know how to help you. Your answers to these questions will not impact your ability to receive individual, group, or peer support services from us.

BLOOM365 staff are Mandatory Reporters, therefore we are required to report disclosures of threats to self or others, and/or physical or sexual abuse of a minor (under 18 years of age) by an adult.

Questions? Contact Erin Callinan, MSW at info@bloom365.org or call/text 602-618-9310
First Name: *
Last Name: *
What is your gender identity? *
What are your pronouns? *
Pronouns are what we use to refer to ourselves or others related to gender identity (i.e he/she/they/ze/hir)
Required
What is your age range? *
Zip Code *
What is your Race/Ethnicity? (check all that apply) *
Required
What is your primary language? *
What is your secondary language? (Skip if not applicable)
Do you identify as LGBTQ+ ? *
Do any of the following apply to you?
At any point in your life have you ever witnessed or experienced victimization of any the following? *
Required
Are you safe right now? *
If you are experiencing a crisis, contact Teen Lifeline at 1-800-248-8336 (TEEN), or call 911 for an emergency.
Clear selection
What are some of your immediate needs or ways that we can help support you? *
Is it okay if we contact you to further discuss your needs? If yes, which are your preferred methods of contact? *
Required
Phone Number
Email Address
Which of the following resources are you interested in? *
Required
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