Appointment Request Form - Pink Positive Psychology®
We're here to support you on your journey to wellness, and filling out this form is the first step toward the care you deserve. We provide telehealth services for adults throughout Michigan and accept most major insurances. Whether you're seeking guidance, healing, or personal growth, we’re ready to help. After submitting, you'll receive a Welcome Message via text/email within 1-2 business days, including your Benefits Quote, Intake Appointment Details, Electronic Forms & Assessments, and a direct link to your clinician’s Virtual Waiting Room. Simply click the link at your scheduled time—no additional setup required. Complete the form below, and let’s begin this journey together!
Client Information
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.
May we contact you via text and/or phone at this number to provide your Benefits Quote and Intake Details?
*
Please Select
Yes
No
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
Mental Health Insurance Details
Do you want to use your Mental Health Insurance?
*
Yes
No, I prefer to pay privately - $200 per session.
Insurance Company
*
Please Select
Aetna
Blue Care Network
Blue Cross Blue Shield - PPO
Blue Cross Blue Shield - FEP
Cigna / Evernorth
HAP (Health Alliance Plan)
HMA / Healthcare Management Administrators
Humana
Optum
Oscar Insurance
Priority Health
United Behavioral Health
UMR / United Medical Resources
UnitedHealthcare / Oxford
UnitedHealthcare Shared Services
UnitedHealthOne / Golden Rule
Where do you obtain your Mental Health Insurance Through?
*
Please Select
Employer (Either Self/Spouse/Parents)
Marketplace (Affordable Care Act)
COBRA Via Employer (either Self/Spouse/Domestic Partner/Parents)
Medicaid (State)
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)
*
Browse Files
Drag and drop files here
Choose a file
Front
Cancel
of
Drivers License (Back)
*
Browse Files
Drag and drop files here
Choose a file
Front
Cancel
of
Insurance Card (Front)
*
Browse Files
Drag and drop files here
Choose a file
Front
Cancel
of
Insurance Card (Back)
*
Browse Files
Drag and drop files here
Choose a file
Back
Cancel
of
Do you have Secondary Health Insurance ?
*
Yes
No
Secondary Insurance? Please provide details below or write N/A = Does NOT Apply
*
Failure to do so CAN result in financial responsibility
Signature
*
Submit
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