Client Application Form

1
Name* This field is required.Name of client seeking therapy
First Name
Last Name
2
Is this you?* This field is required.
YESNO
3
If no, please let us know your name and relationship to the person seeking therapy. Due to HIPAA laws, we are unable to accept applications for adults completing this form on behalf of another adult. If the individual seeking services is 18 years of age or older, they need to complete the form themselves. Failure to follow these instructions will result in dismissal of your application. First Name * Last Name * Relationship *
4
Today's Date
Date
Month
Day
Year
5
Date of Birth* This field is required.Enter the date of birth for the individual seeking services (yourself or adolescent minor, must be at least 12 years old)
Date
Month
Day
Year
6
Age
7
Pronouns* This field is required.Pronouns of client seeking therapy
8
Email* This field is required.Best email address to contact you
example@example.com
9
I'd like occasional resource articles and company alerts sent to this email address: * This field is required.
YESNO
10
Phone Number* This field is required.Best phone number to contact you
Please enter a valid phone number.
11
Address* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
12
Insurance* This field is required.We are in network with Blue Cross Blue Shield PPO and Blue Care Network (BCN) and can submit claims on your behalf when either BCBS PPO or BCN are the Primary Policy. If you have Secondary Insurance, please let our billing department know. We provide out of pocket services to clients who have other insurance plans (BCBS Medicare Advantage, Medicare, Aetna, HAP, Cigna, etc.). Please look at our out-of-pocket costs on our website. The full fee is due at the time of your appointment, and HSA/FSA cards are accepted options for payment. We will provide private pay clients a Superbill so they can seek reimbursement from their insurance. You can read more here: https://www.resetbrainandbody.com/faq
Blue Cross Blue Shield (BCBS PPO)
Blue Care Network (BCN)
Self-Pay/Out of network (Medicare, Aetna, United, etc.)
13
Insurance Information* This field is required.Please provide Member/Subscriber ID (ex: ABC123456789) to verify if you are eligible for in-network services. Incorrect or incomplete information will result in dismissal of your application and you will need to contact Reset to restart the application process.
14
Insurance Information* This field is required.Upload photos of insurance card (front and back)
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
15
Self-Pay Understanding & Rates* This field is required.Please note your understanding of the following: If you do not have BCBS PPO or BCN coverage, we can not submit claims on your behalf. You are considered out of network with our practice and will need to self-pay, pay out of pocket for our services. The rates range from $170-$190 for individual 55 minute sessions depending on the provider you work with. The full fee is due at the time of your appointment, and HSA/FSA cards are accepted options for payment. We will provide self-pay clients a Superbill so they can seek reimbursement from their insurance.
Yes, I understand
I understand, but I have more questions about this
I'm no longer interested and would like referrals where I can use my insurance
16
Services* This field is required.What service is the potential client interested in?
The Individual Reset
The Couples Reset - Waitlist Only
The Team Reset
Reset Workshops
17
Clinical Specialties* This field is required.What clinical focus area would you like support with?
Anxiety
Depression
Stress and Burnout
Sports Performance Coaching
Grief and Loss
Trauma
Chronic Pain and Illness
Perinatal and Postpartum
ADHD and Executive Functioning
Disordered Eating and Body Image
Other
18
Integrative Modalities* This field is required.Reset's approach incorporates integrative modalities to help create the awareness to change reactions to thoughts, life events, people and triggers, in order to help our clients grow, maintain a resilient mindset and live more at peace. Please select which integrative modalities you are interested in.
Somatic Therapy (movement, therapeutic yoga, breath work, body awareness)
Mindfulness-based Cognitive Behavioral Therapy
Foundational Wellness (Rest, Breathe, Connect, Move, Nourish, Rest)
Creative Expression and Art Therapy
Trauma Informed Therapy Practices (EMDR, Brainspotting, Memory Reprocessing)
Deep Healing Modalities (Clinical Hypnosis, Trance Meditation, IFS, Inner Child Healing, Ketamine Assisted Therapy)
No preference at this time
19
Location* This field is required.Which location are you inquiring about? Accessibility Notice: Our Plymouth, Northville, and Ann Arbor offices are ADA accessible. Please note that the Farmington office has stairs at the front entrance, which may present a barrier for individuals with limited mobility. If stairs are a concern, we recommend scheduling sessions at our Plymouth, Northville, or Ann Arbor locations. Virtual sessions are also available as a convenient and accessible option for all clients.
Ann Arbor
Farmington
Northville
Plymouth
Virtual
Any
20
Therapist* This field is required.Is there a specific therapist you're requesting? *If you select a specific therapist, we will do our best to fulfill your request; however, availability cannot be guaranteed and we'll do our best to match you with a therapist that is supportive to your needs.
No, I’m open to your recommendation
Alyssa Ariagno, LMSW
Amber Teunis, LMSW
Amy Zenn, LMSW
Andrea Buckley, LMSW
Ariana Wakeman, LMSW
Bailee Fuhst, LLMSW
Bethany Padilla, LPC
Blaise Fayolle, LPC
Bre Bacile, LMSW
Cady Hadesman, LLMSW
Cara Miller, LMSW-C
Casey Young, LMSW
Chidimma Ozor Commer, PhD, LMSW
Devin Meyrer, LMSW
Emily Schachtele, LMSW
Eriana DeKalita-Mull, LMSW
Holly Gruber, LPC
Imaani Ali, LMFT
Jim Byrne, LPC
Jordyn Kahler, LPC, R-DMT
Kerry Biskelonis, LPC
Kimberly Evans, LLMSW
Lexi Waid, LLP
Lindsay Saie, LMSW
Lisa McIntyre, LPC
Madison Hunwick, LMSW
Mina Kambakhsh, LLMSW
Morgan Durocher, LPC, R-DMT
Neil Sacks, LMSW
Rachel White, LMSW
Sam Breitmeyer, LMSW
Sari Kripke, LMSW
21
Have you ever worked with a therapist at Reset Brain and Body? Do you know or have a prior relationship with anyone working with the requested clinician? Please specify to help us understand if there is any conflict of interest regarding the therapeutic relationship.* This field is required.
22
Would you be open to virtual appointments if it meant you would receive care sooner?* This field is required.
YESNO
23
Availability* This field is required.What is the potential client's schedule availability? Please indicate all possibilities and know that the wait time may be longer for afternoon and evening hours.
Morning (8-11am)
Afternoon (noon-4pm)
Evening (after 5pm)
Weekends (Saturday and Sunday)
Flexible, first available
24
Goals* This field is required.What are the primary concerns/goals you are seeking treatment for?
Huge
Large
Normal
Small
Ok
Ok
25
Have you seen a mental health professional before?* This field is required.
YESNO
26
Diagnosis* This field is required.If yes, do you have an active diagnosis
27
Coping Skills* This field is required.What coping mechanisms have you been using thus far in your life? Why do you think you're in need of more at this time?
Huge
Large
Normal
Small
Ok
Ok
28
On a scale from 1-5, how ready are you to really dig in and do the deep work to overcome your limits and obstacles to get you to the next level?* This field is required.1 indicating not very ready whereas 5 is very ready
1 Not very ready
2 Not ready
3 Somewhat ready
4 Ready
5 Very ready
29
Additional InformationIs there anything else we should know before scheduling your first appointment?
Huge
Large
Normal
Small
Ok
Ok
30
How did you hear about us?* This field is required.
Google
Instagram
Facebook
Psychology Today
Healthcare Provider Referral
Friend/Family Member Referral
School Referral
Other
31
Contact Information Understanding* This field is required.Please note your understanding of the following: Reset is proud to be a paperless office. Per HIPAA laws, no client can be seen by a therapist unless all of our intake paperwork has been completed and submitted. Our paperwork takes about 10-15 minutes and can be completed via tablet, smartphone or computer. Please note, there is no opportunity to complete the paperwork on-site. Therefore, we rely on text message and email reminders from our HIPAA secure platform to communicate with and remind clients of appointments, paperwork, etc.
Yes, I understand
I understand, but I have more questions about this
I'm no longer interested if you require my contact information (phone and email) to be used for session-related communications (appointment reminders)
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