JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
Appointment Request
Please fill out this form and someone on our team will get back to as soon as we can!
Please note: If you are requesting an appointment for a child, we will need all legal guardians to sign intake documentation for children under the age of 14.
Sign in to Google
to save your progress.
Learn more
* Indicates required question
What is your first and last name? If client is a minor, please include their age and parent's name.
*
Your answer
Phone Number:
*
Your answer
Email:
*
Your answer
Primary Health Insurance
*
Aetna/Cofinity
Blue Cross Blue Shield
Blue Cross Complete - Medicaid
Blue Care Network
Priority Health - HMO/PPO
Priority Health Medicaid
Humana
Humana Military
Humana Tricare
Mclaren HMO/PPO
Mclaren Medicaid
Medicaid - unsure of which plan
Meridian HMO/PPO
Meridian Medicaid
Molina HMO/PPO
Molina Medicaid
Optum/UBH/UHC Medicaid
Medicare and Medicaid
Other:
What times are you available for sessions?
*
Mornings
Late Morning/Early Afternoon
Afternoon
Evening if possible
Other:
Required
If you have a preference of which therapist you would like to see, please check their name.
Kimberly Lavender, LMSW - Virtual Only
Tanya Douglas, LMSW - Virtual Only
Amanda Fisher, LMSW - Virtual Only
Mary Gonzales, LLMSW - Virtual Only
Ada Brosier, LMSW - In person and Virtual (Waiting List)
Trudy Willadson, LMFT - In person and Virtual
Tasha Welch, LLMSW - In Person (Waiting List)
Leticia Pellegrino, LLMSW - In person and Virtual
Carmon Ferman, LMSW - In Person and Virtual
Delaney Drumm, MSW Intern - In person and Virtual
Are you looking for in person or virtual sessions?
*
In Person in Greenville MI - I understand there may be a waitlist and I will be contacted once there is an opening.
Virtual
Either
Required
How would you like to be contacted?
*
Please text me
Email would be best
Please give me a call and you can leave a message
Reason for seeking treatment (select one or more)
*
Anxiety
Depression
Trauma and/or PTSD
Addiction
Narcissistic Abuse/ NPD
Relationship Issues
Grief & Loss
Stress Management
Self Exploration & Growth
Life Transitions
Anger Management
Low Self-Esteem
Identity Issues
Parenting Challenges
Workplace Issues
Communication Skills
Sexual Issues
Coping with Abuse
Personality Disorder treatment
Autism
ADHD
Couples counseling
Family therapy
Other:
Required
Additional Comments and Notes:
Your answer
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of Belle Tower Group.
Does this form look suspicious?
Report
Forms
Help and feedback
Help Forms improve
Report
