Appointment Request Form

*Appointment Request Form

Upon receipt of your form I’ll personally send you your Welcome Message - your simple roadmap for getting started. Inside, you’ll find:📅 Your Intake Appointment Date & Time✅ Your Benefits Quote / Good Faith Estimate📝 Your Quick Digital Intake Forms & Assessments🔗 Your Instant Virtual Waiting Room Link - just tap when it’s time. No downloads. No tech stress. Simply reply “C” to Your Welcome Message to confirm Your Intake Appointment. Yes, scheduling it's really that simple!💫 Melissa E. Mendoza, LMSW📍MI
🌿1 OF 2 CLIENT PROFILE
Name*

First NameLast Name
Who Referred You to Individual Counseling? *
Relationship Status*
Date of Birth*

MonthDayYear
Date
Legal Sex (for insurance purposes) *
Tell me a little about what’s been happening that made you decide it’s time for therapy.
Check all that apply*

Anxiety / Racing Thoughts / Always "On Edge"Depression / Low Energy / Chronic Sadness / NumbnessTrauma / Childhood Wounds (ready to process things I’ve pushed down or minimized for years)Relationship / Situationship Pain (feeling stuck in a relationship / marriage, toxic cycle, or “almost relationship” and it’s messing with my peace + identity)People-Pleasing & Boundaries (over-explaining / struggling with boundaries / always putting others first and losing myself in the process)Identity / Self-discovery / Self-Esteem (who am I / what do I want? / tired of feeling like I’m never enough)Family Dynamics & Breaking Generational Patterns (I’m trying to heal cycles I grew up in so they don’t repeat with me)Emotional Regulation (I get overwhelmed, shut down, or react fast — I want better coping tools instead of going straight into survival mode)Breakup or Heartbreak Healing (going through a breakup, situationship, divorce or confusing relationship and I need support untangling my feelings and self-worth)Borderline Personality Disorder / Traits of BPD ((I notice intense emotions, sensitivity to rejection, fear of abandonment, or patterns in relationships that I’m ready to understand and regulate.)
OPTIONAL: In your own words:
Contact Information
Contact Number*
Please enter a valid phone number.Format: (000) 000-0000.
Email Address*
example@example.com
Do you agree to opt-in to receive text messages at this number to provide your Benefits Quote and Intake Details? You may opt-out at any time by replying ‘STOP"*
May we use this email to provide you with your Benefits Quote and Intake Details?*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
💬Choose Your Therapist

Who would you like to work with?
*

Melissa E. Mendoza, LMSW
🗓️ Scheduling Preferences

Select your availability for Intake Appointment: (Check all that apply)
Mondays*

Any Time9AM10 AM11 AM12 PM1PMVaries3:30 PM4:30 PM5:30 PM6:30 PM
Tuesdays*

Any Time9AM10 AM11 AM12 PM1PMVaries
Wednesdays*

Any Time9AM10 AM11 AM12 PM1PMVaries
Thursdays*

Any Time9AM10 AM11 AM12 PM1PMVaries
Fridays*

Any Time9AM10 AM11 AM12 PM1PMVaries
OPTIONAL: Anything else I should know about your schedule or availability?
💳 2 of 2 HEALTH INSURANCE DETAILS

I collect this information to verify your benefits so you have clarity before starting.All uploads are encrypted and HIPAA-secure.
Insurance or Self-Pay — Whatever Fits Best for You 🤍*

Employer Plan (through your job, spouse or parent/s)Marketplace / Affordable Care ActMedicaid (State Insurance)Medicare (Federal Insurance)COBRA (Continuation of Employer Coverage)Self-Pay -$250 per Session
Who Provides Your Mental Health Insurance?*

AetnaBlue Care NetworkBlue Cross Blue Shield – MichiganBlue Cross Blue Shield – Out of StateCigna / EvernorthHAP (Health Alliance Plan)HumanaOptum / UnitedHealthcarePriority Health
Policy Effective Date*

MonthDayYear
Date
Client Relationship to Insured:*
Primary Insured's Employer*
Policy Holder’s First Name*
Policy Holder’s Last Name*
Policy Holder's Date of Birth*

MonthDayYear
Date
Policy ID / Enrollee ID*Include Alpha-Prefix / All Letters*
Group Number*
Drivers License (Front)*

Front
Cancelof
Drivers License (Back)*

Front
Cancelof
Insurance Card (Front)*

Front
Cancelof
Insurance Card (Back)*

Back
Cancelof
Do you have Secondary Health Insurance ?*

YesNo
Have you completed a Coordination of Benefits?*

YesNo
Secondary Insurance Acknowledgment (Required) I have secondary health insurance and understand that coverage is not guaranteed, even if my secondary insurance indicates services may be covered in full.I understand that this practice collects session fees upfront based on my primary insurance benefits (including deductible amounts), regardless of secondary coverage. I understand that I should not complete this form unless I am prepared to pay these upfront costs.I acknowledge that my primary insurance will be billed first, and my secondary insurance will be billed after primary processing. If my secondary insurance pays any portion, any overpayment will be refunded to me.I agree to full financial responsibility for any balance not covered by my insurance plans.*

I understand and agree to the above financial responsibility.
Secondary Insurance Company*

AetnaBlue Care NetworkBlue Cross Blue Shield – MichiganBlue Cross Blue Shield – Out of StateCigna / EvernorthHAP (Health Alliance Plan)HumanaOptum / Oxford / UHCPriority Health
Secondary Insurance: Client Relationship to Insured:*
Secondary Insurance: Insured's Employer*
Secondary Insurance: Policy holder’s name (first and last)*
Secondary Insurance: Policy Holder's Date of Birth*

MonthDayYear
Date
Secondary Insurance: Policy ID / Enrollee ID*Include Alpha-Prefix / All Letters*
Secondary Insurance: Group Number*
Secondary Insurance Card (Front)*

Front
Cancelof
Secondary Insurance Card (Back)*

Back
Cancelof
✍️ Final Step — Sign Below and I'll Take it From Here

Once I review your form, and if it feels like a good therapeutic fit, I’ll personally send you your Welcome Message with your Appointment Details and Next Steps. — Melissa
Signature*
Should be Empty:

*Appointment Request Form

🌿1 OF 2 CLIENT PROFILE

Tell me a little about what’s been happening that made you decide it’s time for therapy.

Contact Information

💬Choose Your Therapist

🗓️ Scheduling Preferences

💳 2 of 2 HEALTH INSURANCE DETAILS

✍️ Final Step — Sign Below and I'll Take it From Here