Contact 1 — Blossoming Minds Counseling, LLC

Waitlist request

This form is for potential clients seeking to be contacted when space opens up with Blossoming Minds Counseling, LLC. Please fill out this form completely. Completion of this form indicates your desire to be placed on a waitlist and in no way starts or guarantees a therapeutic relationship.

Name

First Name

Last Name

Email

Phone

(###)

###

####

Pronouns

I reside in:

Therapist Preference

No Preference - First Available Opening

Jessica Gauthier

Robyn Hunt

Amber Samson

My preferred payment method is:

Please check to indicate understanding of the following:

Waitlist times vary and it may take several months to receive contact.

I am agreeing to be emailed when a spot opens up.

I understand that completion of this waitlist request form does not indicate a therapeutic agreement with Blossoming Minds Counseling, LLC.

If I do not hear from someone in 3 months’ time and I am still looking for a therapist I may complete this form again.

Waitlist request

Blossoming minds counseling, llc