New Patient Enrollment Form

Timber Creek Counseling Intake
Let's get started on your intake form! This form takes around 1-2 minutes to complete.

Do not use this form in case of emergency or if you or your child are feeling suicidal. Instead, please call 911, go to your nearest emergency room, or contact the national suicide hotline at 800-273-TALK (8255).
Your Name*

First NameLast Name
Your Email*
example@example.com
Your Phone Number*
Format: (000) 000-0000.
By continuing, you agree to our Privacy Policy and Terms of Use.

Great! Let's get started.
Who are you seeking care for?*

MyselfSomeone elseMy partner and meMy family and me
Please provide the number of family members that would attend counseling.*
Please provide the ages of the family members who would attend counseling.*

Let's gather a few more details.
Partner's Name*

First NameLast Name
Partner's Email*
example@example.com
Partner's Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Our commitment is to make quality counseling accessible. While our standard session fee is $200, we offer a limited number of reduced rate slots, typically starting from $125, for clients for whom our full fee is not feasible. For rates below $125, additional financial information may be requested to determine eligibility for our sliding scale.*

The standard fee works for me.I am interested in discussing reduced rate options.
Do you have any major unexpected expenses or financial hardships right now?(e.g., recent job loss, large medical bills, unexpected repairs)*

YesNo
If yes, please briefly explain.
Considering your income and essential expenses, what feels like a manageable and fair amount for you to pay per session/service at this time?
What is your estimated total household income per month (after taxes)? Approximate Monthly Income:
What are your most essential monthly expenses? (Think rent, food, basic utilities, transportation, critical medical needs.) Estimated Essential Monthly Expenses:
Considering your income and essential expenses, what feels like a manageable and fair amount for you to pay per session/service at this time?
Thank you for providing us this information. Completing this request does not guarantee a reduced rate. We will follow up with you after reviewing your request.

Thank you! We have just a few more logistical questions left.
What locations would you prefer? (Please select all that apply)*

Ann ArborChelseaVirtualFirst available
Anything we should know about location preferences?

Availability
Are you generally flexible with scheduling, or do you have specific time constraints we should be aware of? (if you have flexibility we are often able to get you in much sooner)*

Generally flexibleTime-specific constraints
To best match you with a therapist, could you please indicate your general availability for weekly sessions? (select all that apply)*

Mornings (8AM-12PM)Afternoons (12PM-4PM)Evenings (4PM or later)
We have a significantly longer wait for evening appointments. Please indicate if you have any flexibility to meet before 4pm on an on-going basis.*

Yes, I can make on-going appointments before 4pm work in order to be seen sooner.No, I need appointments after 4pm and understand this will impact wait time.
Are there any days or times of the week that are consistently unavailable for you?*

YesNo
If applicable, what are your unavailable dates/times?
Thank you for taking the time to provide your availability details. We truly appreciate you filling out those questions thoroughly. This information is invaluable in helping us accurately find a clinician whose schedule aligns with yours.
Anything we should know about your availability?

We are almost there!
To start therapy as soon as possible, are you open to seeing any available counselor?*

YesNo, I only want to be considered for a specific counselor(s) *This will impact wait time*
Please select the preferred counselor

Last questions!
What are the goals/concerns to work on in counseling? Anything else you would like us to know when matching the potential client with a therapist? (200 word max)*

0/200
How did you hear about us?
Should be Empty:

Great! Let's get started.