Intake Form

1
Who is the appointment request for?* This field is required.You can request this appointment for yourself, on behalf of someone else, or for both you and your partner. Please choose below. If you are interested in multiple types of counseling (couples and individual etc.) please submit a separate request for each.
Me
My Partner and Me
Someone Else
2
Couples Counseling Reminder* This field is required.
3
Your Name* This field is required.
First Name
Last Name
4
Your Email* This field is required.
example@example.com
5
Your Phone Number* This field is required.
Please enter a valid phone number.
6
Date of Birth* This field is required.
Date
Month
Day
Year
7
Insurance* This field is required.Before selecting BCBS please confirm it is not a Blue Cross Complete, Blue Cross Medicare, or Blue Care Network plan. Only select providers are in network with BCN and we are out of network with BCC and Blue Cross Medicare.
Blue Cross Blue Shield (BCBS)
Blue Care Network (BCN)
University of Michigan Health Plan (formerly PHP)
Priority Health
Aetna
Cigna
Medicare
Out of Pocket
8
BCBS Reminder
9
Out of Pocket Rate Reminder* This field is required.
10
Partner's Name* This field is required.
First Name
Last Name
11
Partner's Email* This field is required.
example@example.com
12
Partner's Phone Number* This field is required.
Please enter a valid phone number.
13
Partner's Date of Birth* This field is required.
Date
Year
Month
Day
14
Is the potential client a minor?* This field is required.
Yes
No
15
Is your child in a divorced or separated household?* This field is required.
YESNO
16
Do both parents have legal custody?* This field is required.Note: We generally need consent from all custodial parents to proceed with treatment for a minor.
YESNO
17
Please provide the contact information for your child's other legal guardian.* This field is required.
First and Last Name
Email
Phone
What is this guardian's relationship to your child?
18
Potential Client's Name* This field is required.
First Name
Last Name
19
Potential Client's Email
example@example.com
20
Potential Client's Phone Number
Please enter a valid phone number.
21
Potential Client's Date of Birth* This field is required.
Date
Year
Month
Day
22
What services is the potential client interested in?Please fill out one intake for each type of counseling.
Individual Counseling
Couples Counseling
Family Counseling
Child/Adolescent Counseling
23
Please provide the number of family members who will attend counseling.
24
Please provide the ages of each family member.You can separate each age with a comma or semi-colon.
25
What are the main concerns?* This field is required.Please select all applicable concerns.
ADHD
Adoption
Anxiety
Behavioral Issues
Depression
Divorce
Family Conflict
Grief
Impulse Control Issues
LGBTQ+ Issues
Marriage Issues
Men's Issues
Mood Disorders
Obsessive-Compulsive (OCD)
Parenting
Peer Relationships
PMDD
Pregnancy, Prenatal, Postpartum
Relationship Issues
School Issues
Self-Esteem
Spirituality
Stress
Trauma
Women's Issues
EMDR
Other
26
Please rank the locations according to preference
27
What is the potential client's schedule availability?* This field is required.Please indicate all possibilities. The wait time is longer for evening hours.
Morning (8am - 12pm)
Afternoon (12pm-3pm)
Evening (3pm or later)
28
Evening Availability Follow UpWe have a significantly longer wait for evening appointments. Please indicate if you have any flexibility to meet before 3pm on an on-going basis
Yes, I can make ongoing appointments before 3pm work in order to be seen sooner.
No, I need appointments to be 3pm or later and understand this will impact wait time.
29
Daytime Appointments Reminder* This field is required.Please note - if you cannot commit to ongoing daytime appointments, please return to the previous question and de-select the daytime options.
30
What are the goals/concerns to work on in counseling? (150 word max)* This field is required.Please also note here if you have a strong preference for a specific counselor and would like to be considered only for their waitlist. Also please note if you have any specific limitations to your availability. This could affect wait time.
Huge
Large
Normal
Small
Ok
Ok
31
Counselor Availability

Please note - we have many counselors at our practice with availability within the next few weeks. The following therapists currently have closed their waitlist at this time and are unavailable for new clients for the next few months.

-Stephanie Germain, LPC

-Beth Morris, LMSW

-Miles Keller, LPC

-Connor Jewell, LPC

-Dr. Andrew Cuthbert, LP
32
How did you hear about us?
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