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New Client Inquiry Form
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* Indicates required question
Email
*
Your email
Client Name & Pronouns
*
Your answer
Parent/Guardian Name(s) [for children under 18 y/o]
Your answer
Phone Number [please include area code]
*
Your answer
OPTIONAL
: SMS Communication Opt-In
By providing your mobile number and checking this box, you agree to receive
as needed
SMS communications from Amplify Colectivo. Message and data rates will apply. Frequency varies
(Max 3/month)
. Text STOP to unsubscribe or HELP for help. For more details, please review our
Terms & Conditions
and
Privacy Policy.
YES. By checking this box, you agree to receive as needed SMS updates and alerts from Amplify Colectivo at the number provided. Message and data rates may apply. Frequency varies. Text STOP to unsubscribe or HELP for help.
NO, I do want to opt into as needed SMS communication with Amplify Colectivo.
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Client Date of Birth
*
MM
/
DD
/
YYYY
Insurance/Payment Type (Please Note: BCBS & BCN are different insurances. Review your member card for the correct provider)
*
Choose
Blue Care Network (includes UM PremierCare & GradCare)
Blue Cross Blue Shield (BCBS)
Medicaid Blue Cross Complete
Medicaid Meridian
Out of Pocket/Self-Pay
Sliding Scale (I would like more information about this)
Washtenaw Health Plan
Other
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