Register

Registration is only required if you do not have a username. Please check your spam & junk mail folders to ensure you have not already received an email with a username and password. If you already have a username log in here

Each account must have a unique email address associated with it. Please contact us if you need multiple accounts with the same email address (i.e. related family members).

Client Information

/ Middle Initial

( optional )
 
( Must be at least 18 years old )
( MM-DD-YYYY )








(optional) (required)
( for Text Message Reminders )

Bill To Contact

/ Middle Initial







Emergency Contact

First Name
Last Name
Phone
Mobile
Relation
Email
Street Address
City
State
ZIP Code

Log in Details

( If client is a minor, the legal guardian must enter their email address below. )



Between 8 and 40 letters and numbers

Challenge Questions

( These will be used to retrieve your password. Answers must be between 4 and 30 characters, cannot contain any spaces. )




( If you feel you must write down your questions in order to remember them, make sure to keep it in a safe place. )

Terms and Policy

Services, Fee Agreement, No-Show, and Cancellation Policy

All cancellations require 24 hour notice.  Any sessions missed without notification (no-show) will result in the loss of a standing appointment slot after one no show.  2 late/same day cancellations will also result in the loss of a standing appointment slot.


For commercial insurance and self pay clients, missed appointments and late cancellations/same day cancellations without at least 24 hours notice will incur a charge of $100. This fee will be automatically charged to the payment method on file.


In the event that that I am required to appear in legal proceedings for a current or former client, an $800 non refundable minimum fee will be assessed and is due prior to preparation and appearance. When preparation and/or appearance exceeds 8 hours, my normal hourly rate of $130 will be assessed. This includes travel time and is due upon receipt of services. Written reports and other services may be available for an additional fee that will be discussed on a case by case basis.

By signing below I acknowledge that I am responsible for payment of all charges by Bloom Health Coaching and Therapy LLC for cancellations without at least 24 hours notice

( Type Full Name )
( Full Name )