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Contact and Intake Form
Hello, please fill out this form to request an appointment. This form goes directly to our HIPAA compliant, secure mailbox. You will be contacted with instructions for your patient portal to fill out paperwork and have your appointment confirmed.
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Email
*
Your email
Name
*
Your answer
Email Address
*
Your answer
Phone Number
Your answer
Date of Birth (Required for TherapyPortal)
*
MM
/
DD
/
YYYY
Do you have insurance?
*
Yes
No
If so, is it through an employer or through the state?
*
Through an Employer
Through the State of Michigan
An Individual marketplace plan
N/A
My insurance is through:
*
Blue Cross Blue Shield (PPO)
Blue Care Network (HMO) or Blue Cross Complete (Medicaid)
Priority Health (HMO, PPO or Medicaid)
Aetna (HMO, PPO or EAP, NOT Aetna Better Health Medicaid)
N/A
Reason for Therapy (Just a sentence or 2)
Your answer
Availability- Check all that apply (All Sessions are Online)
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
9a
10a
11a
12p
1p
2p
3p
4p
5p
6p
7p
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