*Appointment Request Form
Upon receipt of this form 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. Simply reply “C” to your Welcome Message to confirm your Intake Appointment. Yes, it's really that simple!💫 Melissa E. Mendoza, LMSW📍MI Provider
🌿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
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Please Select
Single
Married
Domestic Partnership
Dating
Situationship
Date of Birth
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-
Month
-
Day
Year
Date
Legal Sex (for insurance purposes)
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Please Select
Male
Female
Other
Tell me a little about what’s been happening that made you decide it’s time for therapy.
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)
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"
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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
3:30 PM
4:30 PM
5:30 PM
6:30 PM
Tuesdays
*
Any Time
9AM
10 AM
11 AM
12 PM
1PM
Varies
Wednesdays
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Any Time
9AM
10 AM
11 AM
12 PM
1PM
Varies
Thursdays
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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 -$250 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 / UnitedHealthcare
Priority Health
Policy Effective Date
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Month
-
Day
Year
Date
Client Relationship to Insured:
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Please Select
Self
Spouse / Domestic Partner
Parent
Primary Insured's Employer
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Policy Holder’s First Name
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Policy Holder’s Last Name
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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
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Group Number
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Drivers License (Front)
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Choose a file
Front
Cancel
of
Drivers License (Back)
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Front
Cancel
of
Insurance Card (Front)
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Front
Cancel
of
Insurance Card (Back)
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Back
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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 / Oxford / UHC
Priority Health
Secondary Insurance: Client Relationship to Insured:
*
Please Select
Self
Spouse / Domestic Partner
Parent
Secondary Insurance: Insured's Employer
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Secondary Insurance: Policy holder’s name (first and last)
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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
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Secondary Insurance: Group Number
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Secondary Insurance Card (Front)
*
Browse Files
Drag and drop files here
Choose a file
Front
Cancel
of
Secondary Insurance Card (Back)
*
Browse Files
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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 you your Welcome Message with your Appointment Details and Next Steps. — Melissa
Signature
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