Appointment Request
Starting therapy is a big deal. We're glad you reached out. Please fill out the information below and our Care Coordination Team will connect with you within 24-48 business hours.
First Name
*
Last Name
*
Date of Birth
*
-
Month
-
Day
Year
Date
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
Best Way to Reach You
Please Select
Call
Text
Email
Service Requested
What service are you interested in?
*
Perinatal Therapy
Infant Mental Health
Child Therapy
Group Therapy/Support Group
Preferred appointment format
*
Please Select
In-Person at Ferndale Clinic
In- Person at Birth Detroit
Virtual/Telehealth
No Preference
Are you a new or returning client?
*
New Client
Returning Client
Have you been in therapy before?
Yes
No
Availability- Please indicate all day/time blocks you are available for us to schedule your appointment.
Weekday Mornings (8am-12pm)
Weekday Midday (12-5pm)
Weekday Evenings (5-8pm)
Weekend Mornings (9am-12pm)
Weekday Mid Day (12-5)
Weekday Evenings (5-8pm)
What Brings You Here
Reasons for Seeking Care
*
Postpartum Depression/Anxiety
Prenatal Mental Health
Pregnancy Loss/Grief
Perinatal Mood Disorder
Anxiety
Depression
Trauma/PTSD
Relationship Issues
Parenting Challenges
Life Transitions
Identity/Self-Esteem
Stress Management
Other
Please share a little about what's going on for you
Insurance & Billing
How will you be paying for services?
*
Please Select
Insurance
Self-Pay
Sliding Scale
Not Sure
Insurance Provider
Please Select
Aetna
BC Complete
BCBS of MI
BCN of MI
Beacon Health
Cigna Behavioral
HAP/Healthplus
Mclaren Commercial
Mclaren Medicaid
Medicaid of MI
Meridian Medicaid
Molina
Optum/UBH/UHC
Priority Health
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