Integrative Empowerment Group, PLLC Appointment Request


***IMMEDIATE OPENINGS***

After you submit this form, we will reach out to confirm contact and your insurance/payment preferences. Our referral coordinator draws from the top of the waitlist and will connect you with a compatible therapist. That therapist will contact you directly via email.  If there are no compatible openings based on availability, insurnace, presenting concerns, etc., we will keep you on the waitlist and continue working to get you placed as soon as possible, but there is not a consistent timeline for how long that might take.

Thank you for your interest in IEG!

*NOTE: FOR CLIENTS SEEKING LETTERS:  We will bypass the waitlist for the short-term service of writing letters for clients seeking gender affirming medical care. This applies to the service of letters only, and not for continuing care after you have received your letter.  Requests for continuing care will still be subject to the waitlist.  We are fine separating those requests.  You can complete the form below, or just email us directly at administration@integrativeempowerment.com 

This Google form is HIPAA compliant and confidential.


Name (first and last) *
Legal Name (if different)
I am seeking therapy for myself at this time *
I am 18 years or older.
 *
Email *
We reply to all requests by email.  Please check the box below to acknowledge that you understand that you will be contacted by email to confirm information, connect with a therapist, and schedule appointments.  *
Required
What is your phone number? *Note our primary mode of communication is email. *
Is it okay to contact you by phone?  Select all that apply. *
Required
We accept the following insurances. Additionally, clients can pay for services out of pocket, including at a sliding scale rate. Please select from the following. *
Required
Which methods of therapy are you open to at this time?  (select as many as apply)

-Significant, and unpredictable wait for in-person sessions.

Notes*
-Per licensing regulations, teletherapy is only available to clients located in Michigan. 
-In-person sessions are held at 124 Pearl Street in Ypsilanti, Michigan, one block from the Ypsi Transit Center.
 *
Required
What is your availability Monday - Sunday 8am-10pm? Please include days and time blocks (e.g. Mondays from 11-3). *
In a few words, tell us what would you like to work on in therapy? *
Are there any identities you hold that you would like us to consider when connecting you with a therapist?  (**Please note that we will use this information to make the best match possible, however we can not guarantee placement based on the responses to this question.) 
Are there qualities/identities in a therapist that are important to you? (**Please note that we will use this information to make the best match possible, however we can not guarantee placement based on the responses to this question.)  
Please describe your accessibility needs. Note our office is ADA compliant.
How did you hear about IEG?
Would you like to receive emails about other IEG services and events?  
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