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FairSky Referral Inquiry Form
FairSky Foundation does not discriminate on the basis of age, gender identity, sexual orientation, race, ethnicity, ability, or any other social identity status. Please note that submission of form is not a guarantee of service, placement is ultimately dependent upon clinician availability, specialty, insurance acceptance, and a number of other factors.
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Name *
Legal Name if different than above (n/a if the same) *
Pronouns *
Date of Birth *
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DD
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YYYY
Phone Number *
Is it okay to leave a detailed message? *
Email Address *
Preferred method of contact *
What service(s) are you seeking? *
Required
If you selected Intimate Partner(s) Therapy and/or Family Therapy (for ages 18+), please provide their full name(s), pronouns, date of birth, and best contact information below.  *
In a few words or sentences, what are you hoping to talk about with a therapist? This will help us best match you to an available clinician. *
Are you interested in in-person services, virtual (telehealth), or are you open to either? *
If seeking in-person services, what location(s) are you interested in?
Are you planning on using insurance? If so, please list the insurance provider(s) and include whether commercial, Medicaid, or Medicare (or combination). Please note: if you have more than one health insurance we will need all of their information. Additionally, we will need pictures of insurance cards emailed to info@fairskymi.org  before proceeding with scheduling. *
Are you comfortable seeing a clinician in training (intern)? All FairSky interns are masters or doctoral level students who are earning degrees in the fields of psychology, social work, or counseling and are being supervised by a fully licensed mental health provider.
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Is there any additional information you would like us to keep in mind? *
How did you hear about us?
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