Basic Info:
Your Name:
*
First Name
Last Name
Email:
*
example@example.com
Phone Number
Please enter a valid phone number.
Age:
*
Where are you located (city, state)?
*
Services:
What type of services are you seeking?
*
Individual therapy for myself
Individual therapy for my child or adolescent
Individual therapy for multiple family members
Couples' Counseling
Other
If you are seeking therapy for someone other than yourself, please provide their full name(s) here:
Is there anything in particular you want or need in a therapist?
We match patients with therapists based on who we believe could be most helpful to you. That said, we understand some people have strong preferences. Please confirm any or all of the boxes that apply to you:
I am open to working with a female therapist
I am open to working with a male therapist
I am open to working with a clinical intern at a reduced fee
Scheduling:
Which office would work best for you (please select all that apply)?
*
Grand Rapids
Saugatuck/Douglas
Online/Virtual
We strongly recommend beginning therapy at least weekly. Are you able to make that commitment?
*
Please Select
Yes,
No
I want to meet more frequently
Which time slots would work on a weekly basis? (check ALL that apply)
*
Mondays
Tuesdays
Wednesdays
Thursdays
Fridays
8am
9am
10am
11am
12pm
1pm
2pm
3pm
4pm
5pm
6pm
How soon are you looking to begin therapy?
*
Finances
Our regular fee is $150 per 45-50 minute session. Is that manageable for you out-of-pocket on a weekly basis?
*
Please Select
Yes
No
Regarding insurance, we are out-of-network providers, meaning we do not work directly with any insurance groups. We keep a credit, debit or HSA card on file to be charged at the time of session, and provide a monthly statement you are welcome to submit to your insurance for partial reimbursement. However, we also have some options in place for those in need of financial assistance. Which of the following best describes you?
*
I do NOT want to involve my insurance, and will pay $150 out of pocket
I can pay the $150, but would like to submit to my insurance for reimbursement
I would like to explore other options for financial assistance
I only want to work with a therapist who is in-network so will seek services elsewhere
Aside from any financial assistance (including insurance) how much do you feel you can manage on a weekly basis?
*
Other Information
How did you hear about us?
*
Please Select
Friend or family member
Mental health professional
Google
Psychology Today
Good Therapy
Theravive
Therapy Den
Zencare
Other
Is there anything else you feel we should know about you from the start?
Do you have any questions you would like answered at this time?
On a scale of 1-5, how ready do you feel to begin therapy?
Not ready
1
2
3
4
Soooo ready
5
1 is Not ready, 5 is Soooo ready
Submit
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