KPS Appointment Request Form
The person seeking treatment prefers to be called
(First name, nickname, Ms. X, Mx. X, etc.)
Pronouns of person seeking treatment
Age of person seeking treatment
We work with patients ages 9+
Please enter a valid phone number.
Who needs help?
Myself & my family
Myself & my partner(s)
My child/dependent (9 - 12 years)
My child/dependent (13 - 17 years)
Issues of concern (check all that apply)
Academic or work problems
Bipolar & mood disorder
General psychological stress or discomfort
Grief & loss
Obsessions and/or compulsions
Psychological testing & evaluation
Couples/marital therapy (Not a covered insurance benefit)
We do not prescribe medication.
Therapist gender preference
No gender preference
Location of service
In office (Detroit)
In office (Ann Arbor)
Either in office or telehealth
Insurance and payment
Blue Cross Blue Shield PPO
Priority Health PPO
Priority Health HMO
Private Pay (Rates vary by clinician)
We are unable to accept Blue Care Network, Beacon, Medicaid, or Medicare. Patients are expected to know their own insurance benefits.
Clinical referral (therapist or physician)
Personal referral (friend or family)
Is there anything else you'd like us to know?
Should be Empty: