*Appointment Request Form
✨ Therapy isn’t about fixing you—it’s about finding you. If relationships, self-doubt, or the heaviness of it all are weighing you down, therapy can help you reclaim your sparkle. You’re not “too much.” You’re the unicorn of your own story. 🦄💫 📋 Please fill out this *required form - share your 🧠 reason/s for seeking therapy (to support a good match), ⏰ preferred days/times, and 💳 insurance or private-pay details. Upon receipt of form you'll receive a Welcome Message with the following: 📅 Intake Appointment Details 💵 Benefits Quote / Good Faith Estimate 📝 Intake E-Forms💻 Melissa's Virtual Waiting Room Link🔗 To Confirm your Intake Appointment, simply reply “C.” Yes, it's really that simple! Melissa E. Mendoza, LMSW @Pink_Psy
Name
*
First Name
Last Name
Who Referred You to Individual Counseling?
*
Please Select
Self-Referred
Friend / Family
Significant Other
My Physician / My Psychiatrist
Court Ordered
Reason(s) for seeking counseling?
*
Relationship Status
*
Please Select
Single
Married
Domestic Partnership
Dating
Situationship
Date of Birth
*
-
Month
-
Day
Year
Date
Administrative Sex
*
Please Select
Male
Female
Other
Pronoun
*
Please Select
he/him
she/her
they/them
Contact Number
*
Please enter a valid phone number.
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"
*
Please Select
Yes, I agree to opt in
No, I do not agree to opt in
Email Address
*
example@example.com
May we use this email to provide you with your Benefits Quote and Intake Details?
*
Please Select
Yes
No
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Scheduling Preferences
Select your availability for Intake Appointment: (Check all that apply)
Mondays
*
Any Time
9AM
10 AM
11 AM
12 PM
1PM
Varies
Tuesdays
*
Any Time
9AM
10 AM
11 AM
12 PM
1PM
Varies
Wednesdays
*
Any Time
9AM
10 AM
11 AM
12 PM
1PM
Varies
Thursdays
*
Any Time
9AM
10 AM
11 AM
12 PM
1PM
Varies
Fridays
*
Any Time
9AM
10 AM
11 AM
12 PM
1PM
Varies
Health Insurance Details
Insurance Company
*
Aetna
Blue Care Network
Blue Cross Blue Shield – Michigan
Blue Cross Blue Shield – Out of State
Cigna / Evernorth
HAP (Health Alliance Plan)
Humana
Optum
Priority Health
Self-Pay – $200 per Session
Client Relationship to Insured:
*
Please Select
Self
Spouse / Domestic Partner
Parent
Primary Insured's Employer
*
Policy holder’s name (first and last)
*
Policy Holder's Date of Birth
*
-
Month
-
Day
Year
Date
Policy ID / Enrollee ID*Include Alpha-Prefix / All Letters
*
Group Number
*
Drivers License (Front)
*
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Front
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of
Drivers License (Back)
*
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Front
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of
Insurance Card (Front)
*
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Front
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of
Insurance Card (Back)
*
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of
Do you have Secondary Health Insurance ?
*
Yes
No
Have you completed a Coordination of Benefits?
*
Yes
No
Secondary Insurance Company
*
Aetna
Blue Care Network
Blue Cross Blue Shield – Michigan
Blue Cross Blue Shield – Out of State
Cigna / Evernorth
HAP (Health Alliance Plan)
Humana
Optum
Priority Health
Secondary Insurance: Client Relationship to Insured:
*
Please Select
Self
Spouse / Domestic Partner
Parent
Secondary Insurance: Insured's Employer
*
Secondary Insurance: Policy holder’s name (first and last)
*
Secondary Insurance: Policy Holder's Date of Birth
*
-
Month
-
Day
Year
Date
Secondary Insurance: Policy ID / Enrollee ID*Include Alpha-Prefix / All Letters
*
Secondary Insurance: Group Number
*
Secondary Insurance Card (Front)
*
Browse Files
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Front
Cancel
of
Secondary Insurance Card (Back)
*
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Back
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of
Sign & Submit
Signature
*
Submit
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