Bloom Adult Referral Form

Bloom Appointment Policy: Scheduled dressing appointments must be at least six months from first and/or second dressing. Maximum of 3 dressings per 5 years.

Note: By attending the appointment, clients give their counselors permission to share employment information with Bloom and permission to use their photo (if taken) in any advertising, newsletter, or publicity. Thank you!

No Childcare Policy. We do not have a waiting area for children, babies, friends, and/or family.

Referring Agency:
Counselor Name:
Counselor Phone:





Appointment:
Spanish Speaker Only:
Race/Ethnicity:
Client's Job Objective:
Sex:
Numeric Pant Size: