*Appointment Request Form
This quick form helps me get to know you — what you’re looking for in therapy, your availability, and how you’d like to handle payment or insurance. It’s designed to make your first session feel smooth, personal, and totally aligned with what you need. Once I’ve reviewed your form and it feels like a good therapeutic fit, I’ll personally send your Welcome Message — your simple roadmap for getting started. Inside, you’ll find:📅 Your Intake Appointment Date & Time✅ Your Benefits Quote / Good Faith Estimate📝 Quick Digital Intake Forms & Assessments🔗 Your Instant Virtual Waiting Room Link — just tap when it’s time. No downloads. No tech stress.To officially lock in your spot, just reply “C” to your Welcome Message — and we’ll make it happen! 💫 Melissa E. Mendoza, LMSW / Pink Psy Counseling
🩷1 OF 2 CLIENT PROFILE
Name
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First Name
Last Name
Who Referred You to Individual Counseling?
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Please Select
Self-Referred
Friend / Family
Significant Other
My Physician / My Psychiatrist
Court Ordered
Relationship Status
*
Please Select
Single
Married
Domestic Partnership
Dating
Situationship
Date of Birth
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-
Month
-
Day
Year
Date
Legal Sex (for insurance purposes)
*
Please Select
Male
Female
Other
Tell me a little about what’s been happening that made you decide it’s time for therapy.(This helps me understand your story and what kind of support you’re looking for.)
Check all that apply
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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)
OPTIONAL: In your own words:
Contact Information
Contact Number
*
Please enter a valid phone number.
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
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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
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Any Time
9AM
10 AM
11 AM
12 PM
1PM
Varies
Tuesdays
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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
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 🤍
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Employer Plan (through your job, spouse or parent/s)
Marketplace / Affordable Care Act
Medicaid (State Insurance)
Medicare (Federal Insurance)
COBRA (Continuation of Employer Coverage)
Self-Pay -$200 per Session
Who Provides Your Mental Health Insurance?
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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
Client Relationship to Insured:
*
Please Select
Self
Spouse / Domestic Partner
Parent
Primary Insured's Employer
*
Policy holder’s name (first and last)
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Policy Holder's Date of Birth
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-
Month
-
Day
Year
Date
Policy ID / Enrollee ID*Include Alpha-Prefix / All Letters
*
Group Number
*
Drivers License (Front)
*
Browse Files
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Choose a file
Front
Cancel
of
Drivers License (Back)
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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 ?
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Yes
No
Have you completed a Coordination of Benefits?
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Yes
No
Secondary Insurance Company
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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
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-
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
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
🩷 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 your Welcome Message with your appointment details and next steps. — Melissa
Signature
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