KPS Appointment Request Form
Name
*
First Name
Last Name
The person seeking treatment prefers to be called
(First name, nickname, Ms. X, Mx. X, etc.)
Pronouns of person seeking treatment
Please Select
She/her/hers
He/him/his
They/them/theirs
Ze/hir
Age of person seeking treatment
*
We work with patients ages 9+
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Who needs help?
*
Please Select
Me
Myself & my family
Myself & my partner(s)
My child/dependent (9 - 12 years)
My child/dependent (13 - 17 years)
Other
Issues of concern (check all that apply)
*
Academic or work problems
Anger
Anxiety
Behavior problems
Bipolar & mood disorder
Depression
LGBTQIA+ concerns
General psychological stress or discomfort
Grief & loss
Obsessions and/or compulsions
Personality disorder
Phobia(s)
Relationship problems
Schizophrenia/psychosis
Trauma/PTSD
Other
Services desired
*
Please Select
Individual therapy
Psychological testing & evaluation
Family therapy
Couples/marital therapy (Not a covered insurance benefit)
We do not prescribe medication.
Therapist gender preference
*
Please Select
Female therapist
Male therapist
No gender preference
Location of service
*
Please Select
In office (Detroit)
In office (Ann Arbor)
Telehealth
Either in office or telehealth
Insurance and payment
*
Please Select
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.
Referral source
*
Please Select
Google
Psychology Today
GoodTherapy
Clinical referral (therapist or physician)
Personal referral (friend or family)
Insurance company
Other
Is there anything else you'd like us to know?
Submit
Should be Empty: