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Interest Form for Mental Health Services
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Legal First and Last Name (and preferred name if different)   *
Name of individual seeking services (if different than above)
Pronouns *
I understand that I MUST live in Michigan to receive services.   *
Email *
Phone Number *
What is your preferred method of communication?
I understand that if I am under 18 years-old, I will be required to have at least 1 guardian consent to treatment.  *
Required
What is the date of birth of the person receiving services?  *
MM
/
DD
/
YYYY
What is your age/the age of the person receiving services?  *
Where did you hear about us?  *
Required
How would you like to pay for services?  *
Required
Please provide a short-description regarding why you (or your child) are seeking services and if using insurance, please write the insurance company name you have as well.  *
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