Information Request Form
Please fill out the following form to be added to our waitlists. We will contact you within 48-72 business hours of completing this form for more information.
Full Name of Person Needing Services
*
First Name
Last Name
Date of Birth of Person Needing Services:
*
-
Month
-
Day
Year
Date
Address of Person Needing Services
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Contact Number of Person Needing Services
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address of Person Needing Services
*
example@example.com
Legal Sex of Person Needing Services:
*
Insurance Policy Information:
Front of Insurance Card:
Back of Insurance Card:
What services are you interested in?
*
Mason - Residential (18+ female) / PHP
Mason Office or Virtual - Intensive Outpatient (IOP)
Mason - Outpatient
Metro Detroit - Outpatient
Wyoming - Outpatient
Responsible Party Information (if client is minor or not responsible for charges):
Does the person needing service require telehealth sessions due to distance/health reasons?
Name of person inquiring about service, if different than the person needing service:
First Name
Last Name
Number of person inquiring about service, if different than the person needing service:
Please enter a valid phone number.
Format: (000) 000-0000.
Relationship of person inquiring to person needing service, if applicable:
Examples: Parent, Spouse etc
Submit
Should be Empty: