Getting Started Form

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Welcome! You're taking a courageous and responsible first step toward wellness. Every person who joins us is treated with compassion, respect, and empathy. We want you to feel wholeheartedly accepted and valued here. Our community deserves nothing less. Every person is capable of an extraordinary life and we are dedicated to helping you achieve your personal wellness goals toward fulfillment and self-empowerment.
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Please be aware this form is fortified with encryption to ensure both security and full compliance with HIPAA regulations. At River Oaks Psychology, we are committed to treating your personal information with the highest level of respect and security. Our dedicated team employs state-of-the-art encryption protocols to ensure the confidentiality of your information.

After you submit this form, we'll contact you to schedule your first appointment!
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Name* This field is required.
First Name
Last Name
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Email* This field is required.
example@example.com
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Phone Number* This field is required.
Please enter a valid phone number.
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Are you seeking therapy services for yourself or someone else?* This field is required.
Myself
Someone else
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What is your Date of Birth?* This field is required.
Date
Month
Day
Year
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Who is the patient?
First Name
Last Name
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Does the patient have an email address? Skip if no.
example@example.com
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Does the patient have a phone number? Skip if no.
Please enter a valid phone number.
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What is the patient's Date of Birth?* This field is required.
Date
Month
Day
Year
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Will you or the patient be located in Michigan at the time of each appointment? This is required even for virtual appointments because our therapists are currently only licensed to practice in Michigan.* This field is required.
YESNO
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Are you or the patient comfortable with telehealth (video) appointments online?* This field is required.
YESNO
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Do you have health insurance?* This field is required.
Yes
No
Yes, but I prefer to pay privately.
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If using health insurance, we will call your insurance to verify that your coverage is active and we'll try to get an estimate of what your insurance will pay for. However, it is ultimately your responsibility to know the details of your coverage. We will bill your insurance for your services here, but if your insurance fails to pay for your services, you are financially responsible. Therefore, we URGE you to fully understand your coverage. Please call the number listed on your insurance card(s) to ask your insurance questions about whether telehealth therapy visits are covered and to ask about your deductible, copays, and other details. Thank you!!
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How many insurance plans are you covered under?* This field is required.
Just my primary insurance
Both a primary and secondary insurance
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Primary Insurance* This field is required.
Insurance Company Name
Policyhollder Full Name (Insurance Subscriber Name)
Date of Birth of the Policyholder
Member ID
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Secondary Insurance* This field is required.
Insurance Company Name
Policyhollder Full Name (Insurance Subscriber Name)
Date of Birth of the Policyholder
Member ID
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Please upload pictures of your insurance cards(s)
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
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To help match you to the right therapist, can you please share the reasons for seeking therapy?
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Small
Ok
Ok
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Is there a particular therapist on our staff that you would like to request?
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Normal
Small
Ok
Ok
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How did you hear about us?
Google
Facebook
Instagram
Twitter
LinkedIn
My doctor referred me
A therapist referred me
Someone else told me about River Oaks
I saw River Oaks staff / table at a community event
Other
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Who referred you to us?
Should be Empty: