Let's Connect

Client Name

First NameLast Name

Email

example@example.com

Client Date of Birth

Date

Is the client a minor?

Parent/Guardian Name

First NameLast Name

Parent/Guardian Date of Birth

MonthDayYear

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Primary Concern:

Type of Service Requested:

Do you have any ongoing legal concerns that will require case management? This includes court ordered services, child custody cases, divorce etc.

If you answered yes or maybe to the previous question, please explain.

Please select the primary insurance provider you use. You may opt out of using your commercial insurance as well. If you're unable to use your insurance, you may be able to use Out of Network benefits. This may or may not change the cost for your service.

Do you have a secondary insurance?

Please select the secondary insurance provider you use. This may or may not change the cost for your service.

If you selected other, please type your insurance plan below. Please note that we do not accept most Medicaid.

Member ID # located on the front of your insurance card and/or EAP Authorization #

Customer service number on back of your insurance card.

Relationship to client:

What days work best for you?

What time of day works best for you?

By filling out this form, you understand that all services are conducted via telehealth only and that you must physically residing in Michigan to request services. By filling out this form, you will be subscribed to our mailing list. It is used to send out information about groups, closures, and other important announcements for the practice.

By filling out this form, you will be subscribed to our mailing list. It is used to send out information about groups, closures, and other important announcements for the practice.

How did you hear about us?

Questions/ concerns:

What is the best way to contact you?