*Request An Appointment
Hi! I'm Melissa an empath with a passion for helping people. Ready for Change? Complete this secure form so I can review your needs, availability, and insurance or self-pay details and determine whether we may be a good therapeutic fit. Within 1–2 business days of reviewing your form, I’ll personally send you your Welcome Message with your Appointment Details: Benefits Quote or Good Faith Estimate / E-Forms and Assessments / Virtual Link, and Next Steps. Simply reply “C” to Confirm. 💫 Warmly, Melissa E. Mendoza, LMSW-C 📍 Michigan
What are you using this form for today?
*
Please Select
New Client > First Appointment
Existing Client > New Health Insurance
Former Client > Return to Therapy
First Name
*
Last Name
*
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
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 / Numbness
Trauma / 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.)
I'll tell you more in session.
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."
*
Please Select
Yes, I agree to opt in
No, I do not agree to opt in
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 PreferencesSelect your availability for Intake Appointment: (Check all that apply)
Mondays
*
Anytime
9 AM
10 AM
11 AM
12 PM
1 PM
3:30 PM
4:30 PM
5:30 PM
Varies
Select All that Apply
Tuesdays
*
Anytime
9 AM
10 AM
11 AM
12 PM
1 PM
Varies
Select All that Apply
Wednesdays
*
Anytime
9 AM
10 AM
11 AM
12 PM
1 PM
Varies
Select All that Apply
Thursdays
*
Anytime
9 AM
10 AM
11 AM
12 PM
1 PM
Varies
Select All that Apply
Fridays
*
Anytime
9 AM
10 AM
11 AM
12 PM
1 PM
Varies
Select All that Apply
🛡️ Insurance Information so we may promptly verify your insurance and provide you with a benefits quote!
Who Provides Your Mental Health Insurance?
*
Please Select
Aetna
Blue Care Network
BCBS of MI
BCBS - Out of State
Cigna / Evernorth
HAP / Health Alliance Plan
Humana
Optum / UnitedHealthcare
Priority Health
POLICY HOLDER: Client Relationship:
*
Please Select
Self
Spouse
Child of
Primary Insured's Employer
*
Primary Policy Holder’s First Name
*
Primary Policy Holder’s Last Name
*
Primary Policy Holder's Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Policy ID# / Enrollee ID#
*
Group Number
*
Driver's License (Front)
*
Browse Files
Drag and drop files here
Choose a file
Front
Cancel
of
Driver's License (Back)
*
Browse Files
Drag and drop files here
Choose a file
Back
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
Have you completed a Coordination of Benefits?
*
Yes
No
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
*
Aetna
Blue Care Network
Blue Cross Blue Shield – Michigan
Blue Cross Blue Shield – Out of State
Cigna / Evernorth
HAP (Health Alliance Plan)
Humana
Optum / Oxford / UHC
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
2 digit month, 2 digit day, 4 digit year
Date
Secondary Insurance: Policy ID / Enrollee ID*Include Alpha-Prefix / All Letters
*
Secondary Insurance: Group Number
*
Secondary Insurance Card (Front)
*
Browse Files
Drag and drop files here
Choose a file
Front
Cancel
of
Secondary Insurance Card (Back)
*
Browse Files
Drag and drop files here
Choose a file
Back
Cancel
of
By signing below, I certify that all information provided in this Appointment Request—including all current Primary and Secondary insurance coverage—is true, complete, and accurate as of the date signed. Signature
*
Send My Appointment Request
Should be Empty: