Client Date of Birth
Please enter a valid phone number.
Type of Service Requested:
Individual Therapy for Adult (ages 18+)
Individual Therapy for Adolescents/Teens (ages 11-17 - select providers only)
Mental Health Education/Speaking/Training
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 insurance provider you use. You may opt out of using your 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.
Blue Cross Blue Shield
Blue Care Network
Priority Health Medicaid
Open Path Collective
The Loveland Foundation
No Insurance (Private Pay)
Opting out of using insurance (Private Pay)
Out of Network (you can receive a superbill for your services)
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?
Evening 5pm or later
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?
Therapy for Black Girls
My Insurance / EAP
Word of Mouth
Space For Change Therapeutic Services Website
Mental Health Clinicians of Color
Melanin & Mental Health
What is the best way to contact you?
Should be Empty:
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