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. Please note, our therapists are only licensed in the state of Michigan, therefore we can only see clients who live in the state (with the exception of residential treatment).
Full Name of Person Needing Services
*
First Name
Last Name
Date of Birth of Person Needing Services:
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit 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 / PHP (18+ female)
Adult Intensive Outpatient (IOP) - Mason Office or Virtual
Adolescent Intensive Outpatient (IOP) - Metro Detroit Office or Virtual
Mason - Outpatient
Metro Detroit - Outpatient
Wyoming - Outpatient
Outpatient, Telehealth ONLY (if far away from any office)
Are you interested in any other programs besides the one you selected above?
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: