Updated Patient Enrollment FINAL

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Contact Information* This field is required.By providing your contact information, you consent to being contacted in response to this inquiry by our practice via email, phone, voicemail, or text.
Please Select (scroll for all options)
Please Select (scroll for all options)
Myself
Someone else
My partner and me
My family and me
Who are you seeking care for?
First Name
Last Name
Phone
Please enter your email
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Please provide the number of family members that would attend counseling.* This field is required.
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Please provide the ages of the family members who would attend counseling.* This field is required.
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Partner Contact Information
First Name
Last Name
Email
Phone Number
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Address* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
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Potential Client Legal NameIf using insurance this must match what is on file with your insurance company.
First Name
Last Name
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Potential Client Date of Birth* This field is required.
Date
Month
Day
Year
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Date Now
Date
Month
Day
Year
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Age
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Potential Client Email* This field is required.Because the potential Client is over 18 or older we need their email to contact them for the initial paperwork and scheduling. Please provide that email below.
example@example.com
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Is your child in a divorced or separated household?* This field is required.
Yes
No
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Do both parents have legal custody? *Note: We generally need consent from all custodial parents to proceed with treatment for a minor.** This field is required.
Yes
No
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Please provide the contact information for your child's other legal guardian.* This field is required.
First Name
Last Name
Email address
Phone Number
What is the guardian's relationship to your child?
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How are you planning to pay for care?* This field is required.
Insurance
Self Pay
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Insurance or self pay
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Our practice does not bill insurance for couples counseling. While our standard session fee is $200, we offer a limited number of reduced rate slots, typically starting from $125, for clients for whom our full fee is not feasible. For rates below $125, additional financial information may be requested to determine eligibility for our sliding scale.* This field is required.
The standard fee works for me.
I am interested in discussing reduced rate options.
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Our commitment is to make quality counseling accessible. While our standard session fee is $200, we offer a limited number of reduced rate slots, typically starting from $125, for clients for whom our full fee is not feasible. For rates below $125, additional financial information may be requested to determine eligibility for our sliding scale.* This field is required.Completing this request does not guarantee a reduced rate. We will follow up with you after reviewing your request.
The standard fee works for me.
I am interested in discussing reduced rate options.
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Do you have any major unexpected expenses or financial hardships right now?(e.g., recent job loss, large medical bills, unexpected repairs)* This field is required.
Yes
No
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If yes, please briefly explain.
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Considering your income and essential expenses, what feels like a manageable and fair amount for you to pay per session/service at this time?* This field is required.
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$150
$125
Below $125
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What is your estimated total household income per month (after taxes)? * This field is required.
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What are your most essential monthly expenses? (Think rent, food, basic utilities, transportation, critical medical needs.)* This field is required.
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Considering your income and essential expenses, what feels like a manageable and fair amount for you to pay per session/service at this time?* This field is required.
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Out of Pocket Amount
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Insurance Information* This field is required.Additional information will be requested for us to submit claims on your behalf.
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Blue Cross Blue Shield
Blue Care Network (BCN)
Priority Health
Cigna
Aetna
HAP
Medicare
University of Michigan Health Plan
Primary Insurance
Please Select
Please Select
Female
Male
Potential Client's Sex (as on file with insurance company)
What is the potential client's relationship to the subscriber?
What is the potential client's relationship to the subscriber?
Self
Spouse
Child
Other
Subscriber relationship
Please Select
Please Select
I have my member ID can provide it now.
I will wait to provide my member ID.
Identification
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Additional Insurance Information* This field is required.
Member ID
Subscriber First Name
Subscriber Last Name
What is the subscriber's date of birth?
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Please Select
Female
Male
Subscriber's Sex (as on file with insurance company)
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What are the main concerns?Select all that apply.
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ADHD
Adoption
Anxiety
Behavioral Issues
Depression
Divorce
Family Issues
Grief
LGBTQ Issues
Men's Issues
Mood Disorders
Obsessive-Compulsive (OCD)
Parenting
Peer Relationships
Pregnancy, Perinatal, Postpartum
Relationship Issues
School Issues
Self-Esteem
Spirituality
Stress
Trauma
Women's Issues
Other
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Please indicate your preference for matching with a counselor below.* This field is required.Please know: We do our best to find a good fit for each person. Occasionally, someone’s needs may be better served in a different type of setting or with a more specialized provider. If that’s the case, we’ll offer thoughtful referrals to help you get the right care.
You choose for me — Match me with someone who fits my needs and availability.
I’ll choose myself — Send me a scheduling link to see eligible clinicians and book my own session.
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What location would you prefer?* This field is required.Select all that apply.
Ann Arbor
Chelsea
Virtual
Location
Anything we should known about your location preferences?
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Availability* This field is required.
Mornings (8AM-12PM)
Afternoons (12PM-4PM)
Evenings (4PM or later)
Please indicate your general availability.
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Please Select
Generally flexible
Time-specific constraints
Are you generally flexible or do you have time specific constraints?
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Please Select
Yes, I can make on-going appointments before 4pm.
No, I need appointments after 4pm.
We have a significantly longer wait for evening appointments. Please indicate if you have any flexibility to meet before 4pm.
Anything we should know about your availability?
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What are the goals/concerns to work on in counseling? Anything else you would like us to know when matching the potential client with a therapist? (200 word max)* This field is required.
0/200
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How did you hear about us?
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Clinician Name
First Name
Last Name
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Clinician Email
example@example.com
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Client Account Email
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Matching Email
example@example.com
Should be Empty: