Welcome!
Hi, welcome! This form helps me get to know you and understand your needs, identity, and safety preferences. You don’t have to answer anything you’re not comfortable sharing — your privacy and safety are my top priorities.
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Which type of name will you be using for this form?
*
Legal Name
Preferred Name
Alias
Name
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Contact & Safety
Please share the best ways to reach you. If you need extra privacy, feel free to use a secure phone or email. You can skip anything that doesn’t feel safe to share.
Preferred Contact Method
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Why You're Seeking Therapy
I’d love to hear what’s going on for you right now and what you’d like support with. There’s no right or wrong answer — just whatever feels most important to you.
Current Concerns/Goals/Stressors
Identity & Background
Understanding your identity helps me create a safe, affirming space. You don’t have to share anything you’re not comfortable with.
What do you want me to know about you before we start?
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Insurance or Cash Pay
You can choose to use insurance or pay out-of-pocket. If you choose cash-pay, you can select a sliding scale fee that works for you. All clients get the same quality of care, no matter what tier you choose.
I will be using insurance
Please Select
Aetna
Atlantic Medical Insurance
BCBS Federal
BLUE CARE NETWORK
Blue Cross Blue Shield of Michigan
Blue Cross Complete of Michigan
Cigna
First Health Network (Coventry)
GEHA
McLaren Health Plan
MERIDIAN COMPLETE MICHIGAN
Meridian Medicare Medicaid Plan
MI Blue Care Network
Michigan Medicaid
Molina Healthcare of Michigan
Priority Health
TriCare
UMR
GEHA
I will be doing cash-pay
Please Select
$15 per session (limited income & financial hardship)
$30 per session (steady but limited income)
$50 per session (moderate financial stability)
$75 per session (higher financial flexibility)
Crowdfunded Therapy
You can pick a different tier for each session or package, depending on what feels manageable for you. Choosing a higher tier helps support the sliding scale program.
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Thank you for taking the time to fill this out.
I know forms like this can sometimes feel vulnerable or tiring, and I appreciate the effort it took to share about yourself. Everything you shared helps me understand how to support you better and make sure our work together is a good fit. Once you submit this form, I’ll review your responses and reach out within 24 hours using your preferred contact method. If it seems like we’re a good fit, we’ll schedule your first session and go over any remaining questions together.
A few reminders...
You are always welcome to use the name you feel safest using. If you selected cash-pay, you can choose a different sliding scale tier each time you schedule if your situation changes. You can switch to cashpay at any time. Your privacy and safety are important to me, and your information is handled with care. I’m glad you reached out.
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