Date
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Contacts First name
*
Parent' or Submitter's First Name
Contacts Last Name
*
Parent' or Submitter's Last Name
Phone Number
*
Format: (000) 000-0000.
E-mail
*
example@example.com
Client's Name
*
First Name
Last Name
How old are they?
*
Please tell us the best day and time to contact you.
*
Insurance (please note if you don't see your specific child's Medicaid HMO or commercial insurance on this list we do not participate with them)
*
Please Select
Automobile Insurance
Aetna
Blue Cross Blue Shield
Blue Care Network
United Health Care / UMR - Commercial
United Healthcare Medicaid
McLaren Medicaid
Priority Health - Commercial
Other (if other please indicate what type in comments. If your insurance is not on this list we are out of network)
What service are you most interested in?
Please Select
Therapy
Medication Management
Psychological Testing
Teen Intensive Outpatient Therapy
Comments (please state the reason[s] you are seeking counseling for yourself or your child).
*
How did you hear about us?
*
Please Select
Facebook
Google
Word of Mouth
PCP or Pediatrician
I consent to being contacted at the email or phone number I have provided. The information that I have provided is true and accurate to the best of my knowledge.
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Please verify that you are human
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